Aphasia treatment: intensity, dose parameters, and script training

Quantifying Dosage in Self-Managed Speech-Language Therapy: Exploring Components of Cumulative Intervention Intensity in a Real-World Mobile Health Data Set

PURPOSE

Cumulative Intervention Intensity (CII) is a proposed framework for conceptualizing and calculating dose that has been used to quantify intensity of speech-language therapy (SLT) in highly controlled laboratory studies and clinical trials. However, it is unknown whether CII can be applied to characterize the practice patterns of patients undertaking at-home, self-managed SLT. The current study leverages real-world mobile health data to investigate the applicability of CII parameters to self-managed SLT, including the interrelationships between individual CII parameters and their utility for identifying naturally occurring subgroups of patient users.

METHOD

Anonymized data from 2,223 poststroke survivors who used the Constant Therapy application were analyzed. Four quantitative CII parameters-dose, session frequency, session duration, and total intervention duration-were calculated per user over a 3-month analysis period using raw session-level data. We conducted correlation analyses at the level of the individual and group to examine the degree of relatedness between each of the CII parameters. CII parameter measures were additionally used as inputs to a k-mean clustering analysis to identify practice pattern subgroups.

RESULTS

Results demonstrate the feasibility of calculating components of CII based on available usage statistics from a commercial app for self-managed SLT. Specifically, results suggest that, although CII parameters are related, session frequency offers complementary and nonoverlapping information (cf. dose, session duration, total intervention duration) about dosage. Clustering results show that practice patterns can be broadly differentiated according to the (a) amount and (b) frequency of practice.

CONCLUSIONS

The calculation of CII may provide both users and clinicians with a fuller picture of at-home, self-managed practice habits than looking at any one dosage component alone. The study represents a first step toward more comprehensive and theoretically grounded dose reporting for self-managed SLT.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25511191.

Examining Therapy Duration in Adults With Voice Disorders

PURPOSE

This study examined the number of voice therapy sessions and the number of weeks in treatment to achieve desired voice outcomes in adults with voice disorders. Factors that may predict therapy duration were examined, as was the percentage of patients returning to the clinic for additional voice therapy after initial discharge.

METHOD

An observational cohort design was utilized. Data from 558 patients were extracted from the University of Wisconsin-Madison Voice and Swallow Outcomes Database. Patients diagnosed with muscle tension dysphonia, vocal fold paralysis, benign vocal fold lesions, laryngospasm/irritable larynx, and presbyphonia were examined. Patient demographics, auditory-perceptual assessments, acoustics, aerodynamics, videostroboscopy ratings, self-reported scales, and medical comorbidities were collected.

RESULTS

Patients required an average of 5.32 (SD = 3.43) sessions of voice therapy before voice outcomes were sufficiently improved for discharge. Average number of sessions ranged from 4.3 for presbyphonia to 6.7 for benign vocal fold lesions. Baseline overall Grade Roughness Breathiness Asthenia and Strain rating (p < .001), Dysphonia Severity Index (p < .001), Voice Handicap Index score (p < .01), age (p = .006), and occupational voice user status (p < .001) significantly predicted the number of therapy sessions required. Overall, 14.5% of patients returned for additional voice therapy following an initial discharge from treatment.

CONCLUSIONS

Findings inform our understanding of how many sessions patients with voice disorders require to achieve desired voice outcomes. Additional research is needed to optimize the efficacy of voice treatment and determine how recurrence of dysphonia might best be prevented.

A randomized crossover single-case series comparing blocked versus random treatment for anomia

The motor learning literature has demonstrated that blocked practice facilitates better acquisition of motor skills, whereas random practice facilitates retention and transfer. The verbal learning and memory literature offers similar evidence. The purpose of this study was to investigate effects of blocked versus random practice in treatment for anomia. The study used a single site, randomized crossover design, with two replicated experimental phases (two blocked and two random) for each of 10 individuals with anomia. Each phase consisted of a cued picture-naming treatment. Individual treatment and maintenance effects, as well as weighted averages and group effects, were calculated using Tau-U based on the proportion of correctly named probes. Nine of 10 participants demonstrated treatment effects during each of the four phases. Acquisition was comparable for blocked and random practice. Maintenance effects were observed following seven blocked phases of treatment and 12 random phases of treatment across participants. For four of 10 participants the random schedule resulted in better maintenance of trained items. Although further research is needed, the present data suggest that for word retrieval treatment with multiple repetitions of the same items, a random presentation may benefit maintenance of treatment gains.

Speech and Language Therapy for Acquired Central Dysgraphia in Neurological Patients: A Systematic Review to Describe and Identify Trainings for Clinical Practice

PURPOSE

Acquired central dysgraphia is a heterogeneous neurological disorder that usually co-occurs with other language disorders. Written language training is relevant to improve everyday skills and as a compensatory strategy to support limited oral communication. A systematic evaluation of existing writing treatments is thus needed.

METHOD

We performed a systematic review of speech and language therapies for acquired dysgraphia in studies of neurological diseases (PROSPERO: CRD42018084221), following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist with a search on several databases for articles written in English and published until August 31, 2021. Only methodological well-designed studies were included. Further assessment of methodological quality was conducted by means of a modified version of the Downs and Black checklist.

RESULTS

Eleven studies of 43 patients in total were included. For each study, we collected data on type of population, type of impairment, experimental design, type of treatment, and measured outcomes. The studies had a medium level of assessed methodological quality. An informative description of treatments and linkages to deficits is reported.

CONCLUSIONS

Although there is a need for further experimental evidence, most treatments showed good applicability and improvement of written skills in patients with dysgraphia. Lexical treatments appear to be more frequently adopted and more flexible in improving dysgraphia and communication, especially when a multimodal approach is used. Finally, the reported description of treatment modalities for dysgraphia in relation to patients' deficits may be important for providing tailored therapies in clinical management.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Improving Functional Communication Outcomes in Post-Stroke Aphasia via Telepractice: An Alternative Service Delivery Model for Underserved Populations

Many persons with aphasia (PWA) have limited access to speech-language treatment (SLT) due to limited funding, speech-language pathologist shortages, geographical barriers, physical disabilities, transportation barriers, and the COVID-19 pandemic. The purpose of this study was to determine if telepractice is an effective and feasible service delivery model for PWA. Ten PWA completed 8 hours of remote treatment over 4 weeks. Synchronous telepractice sessions employed Oral Reading for Language in Aphasia (ORLA) and Conversational Script Training (CST). Pre- and post-assessment outcome measures included the Communication Activities of Daily Living-3 (CADL-3) and the Communication Confidence Rating Scale for Aphasia (CCRSA). Participants completed a telepractice satisfaction survey following post-assessment. All participants demonstrated improvements in CCRSA scores, total words produced correctly on trained CST stimuli, and total words produced correctly on trained ORLA stimuli. No differences were noted in CADL-3 scores. All participants were highly satisfied with telepractice as a service delivery model.

Pediatric Voice Therapy: How Many Sessions to Discharge?

PURPOSE

Voice therapy is the primary treatment for children presenting with benign morphological vocal fold changes. This study examined the number of voice therapy sessions required to meet treatment goals and identified factors that predicted treatment length for pediatric voice patients.

METHOD

An observational cohort design was employed. Data were extracted from the University of Wisconsin-Madison Voice and Swallow Outcome Database. This study examined 62 children who completed a course of voice therapy with a speech-language pathologist (SLP) addressing dysphonia caused by benign vocal fold lesions. Extracted data included patient demographics, auditory-perceptual assessments, acoustic and aerodynamic voice measures, videostroboscopy ratings, and medical comorbidities. Linear regression was used to identify predictors of number of therapy sessions.

RESULTS

Patients received an average of 7.5 sessions of voice therapy prior to discharge. Baseline auditory-perceptual assessment of dysphonia (p = .032), phonation threshold pressure (PTP, p = .005), Glottal Function Index (GFI) score (p = .006), and glottic closure pattern (p = .023) were significant predictors of number of voice therapy sessions. These measures, as well as hourglass glottic closure, predicted longer intervention duration. The regression model had an overall r ² of .62.

CONCLUSIONS

Pediatric voice therapy addressing benign vocal fold lesions and/or laryngeal edema required an average of 7.54 sessions before voice outcomes were sufficiently improved for discharge. More severe overall SLP ratings of dysphonia, GFI scores, PTP, or hourglass glottic closure pattern significantly predicted increased number of therapy sessions prior to discharge. Future work should determine what other factors affect treatment duration and how the efficiency of pediatric voice therapy can be maximized.

Timing of transcranial direct current stimulation (tDCS) combined with speech and language therapy (SLT) for aphasia: study protocol for a randomized controlled trial

BACKGROUND

Studies suggest that language recovery in aphasia may be improved by pairing speech-language therapy with transcranial direct current stimulation. However, results from many studies have been inconclusive regarding the impact transcranial direct current stimulation may have on language recovery in individuals with aphasia. An important factor that may impact the efficacy of transcranial direct current stimulation is its timing relative to speech-language therapy. Namely, online transcranial direct current stimulation (paired with speech-language therapy) and offline transcranial direct current stimulation (prior to or following speech-language therapy) may have differential effects on language recovery in post-stroke aphasia. Transcranial direct current stimulation provided immediately before speech-language therapy may prime the language system whereas stimulation provided immediately after speech-language therapy may aid in memory consolidation. The main aim of this study is to investigate the differential effects of offline and online transcranial direct stimulation on language recovery (i.e., conversation) in post-stroke aphasia.

METHODS/DESIGN

The study is a randomized, parallel-assignment, double-blind treatment study. Participants will be randomized to one of four treatment conditions and will participate in 15 treatment sessions. All groups receive speech-language therapy in the form of computer-based script practice. Three groups will receive transcranial direct current stimulation: prior to speech-language therapy, concurrent with speech-language therapy, or following speech-language therapy. One group will receive sham stimulation (speech-language therapy only). We aim to include 12 participants per group (48 total). We will use fMRI-guided neuronavigation to determine placement of transcranial direct stimulation electrodes on participants' left angular gyrus. Participants will be assessed blindly at baseline, immediately post-treatment, and at 4 weeks and 8 weeks following treatment. The primary outcome measure is change in the rate and accuracy of the trained conversation script from baseline to post-treatment.

DISCUSSION

Results from this study will aid in determining the optimum timing to combine transcranial direct current stimulation with speech-language therapy to facilitate better language outcomes for individuals with aphasia. In addition, effect sizes derived from this study may also inform larger clinical trials investigating the impact of transcranial direct current stimulation on functional communication in individuals with aphasia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03773406. December 12, 2018.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Usability and Acceptability of a Computer-Based Social Communication Intervention for Persons with Traumatic Brain Injury: A Mixed-Methods Study

Computer-based interventions for persons with traumatic brain injury (TBI) are a rapidly developing treatment modality. However, the usability and acceptability of such treatments have not been thoroughly studied. We describe the user-experience of a computerized intervention in persons with TBI called the Work-Related Communication (WoRC) program. Two coders used qualitative analysis of semi-structured interviews to complete a thematic content analysis along with a cost-benefit analysis. Ten participants with severe TBI more than 1-year postinjury were interviewed. Seven participants were male, and three were female. Their mean age was 41.6 years (standard deviation: 13.1). All had 4 years of college or less and experienced severe TBIs. A qualitative analysis of the WoRC program usability resulted in the categories of Content (aspects of treatment approach), Interface (aspects of presentation), and Abilities (aspects of the cognitive disorder). WoRC program acceptability categories emerged as Specific (trained strategies can be applied to specific scenarios) and Personal (individual factors related to willingness to implement the trained strategies). The cost-benefit analysis demonstrated a 50.2% reduction in treatment costs, indicating that computer-enhanced interventions are a potentially cost-effective way to increase behavioral outcomes. We discuss these findings as they relate to future development of computer-enhanced programs for persons with TBI.

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

Background

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

Methods

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

Results

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

Conclusions

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

Complexity and feedback during script training in aphasia: A feasibility study

OBJECTIVE

To explore the impact of complexity and feedback on script training outcomes in aphasia DESIGN: Randomized balanced single-blind 2 × 2 factorial design SETTING: Freestanding urban rehabilitation hospital.

PARTICIPANTS

Adults with fluent and nonfluent aphasia (at least six months post-onset).

INTERVENTIONS

Experimental treatment was AphasiaScripts®, a computer-based script training program. Scripts were 10-turns long and developed at different complexity levels to allow for comparison of high versus low complexity. The program was modified to contrast high versus low feedback conditions during sentence practice. Participants were instructed to practice three 30-minute sessions per day, six days a week for three weeks.

MAIN MEASURES

Gains achieved from baseline in accuracy and rate of production of trained and untrained script sentences at post-treatment and at 3-, 6- and 12-weeks after the end of treatment.

RESULTS

Sixteen participants completed the intervention. On the trained script, gains were statistically significant for both accuracy and words per minute, at post-treatment and 3-, 6- and 12-week maintenance. Gains on the untrained script were smaller than on the trained script; they were statistically significant only for accuracy at post-treatment and 3-week maintenance. Complexity had an influence on accuracy at post-treatment (F(1) = 4.8391, p = 0.0501) and at maintenance (F(1) = 5.3391, p = 0.04125). Practicing scripts with high complexity increased accuracy by 11.33% at post-treatment and by 9.90% at maintenance compared to scripts with low complexity. Participants with nonfluent aphasia made greater gains than those with fluent aphasia. There was no significant effect of feedback.

CONCLUSION

This study reinforces script training as a treatment option for aphasia. Results highlight the use of more complex scripts to better promote acquisition and maintenance of script production skills. There is a need for further investigation of these variables with larger samples and with other types of aphasia treatments.

CLINICALTRIALS

gov identifier: NCT01597037.

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.

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

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

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

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

The effects of intensity on a phonological treatment for anomia in post-stroke aphasia

INTRODUCTION

The evidence regarding optimal treatment intensity is mixed, and differing definitions have further confounded existing findings. The primary objective of this study was to compare the efficacy of Phonological Components Analysis (PCA) treatment for anomia delivered at intense and non-intense schedules, using a well-controlled design. The number of teaching episodes and active ingredients of therapy are important considerations when defining intensity. We hypothesized that an active ingredient of PCA is the self-generation of phonological components during therapy sessions. Our secondary aim was to examine whether component generation predicted treatment outcome.

METHODS

Sixteen adults (M = 52.63 years old, SD = 11.40) with chronic post-stroke aphasia (M = 4.52 years post-onset, SD = 5.55) were randomly assigned to intensive (IT) or standard (ST) PCA treatment conditions. Cumulative treatment intensity in both conditions was equivalent: ST participants received PCA 1 hour/day, 3 days/week for 10 weeks, whereas IT participants received PCA 3 hours/day, 4 days/week for 2.5 weeks. The primary outcome was naming accuracy on a set of treated and (matched) untreated words, measured pre- and post-treatment, and at four- and eight-week follow-ups.

RESULTS

IT and ST conditions were similarly efficacious. However, secondary analyses suggest an advantage for the IT condition in naming of the treated words immediately post-treatment, but not at follow-ups. The self-generation of phonological components emerged as a significant positive predictor of naming accuracy for both the treated and untreated words. However, this relationship did not reach significance once baseline anomia severity was accounted for.

CONCLUSIONS

Although replication in a larger sample is warranted, results suggest that PCA treatment is similarly efficacious when delivered at different intensities. Other factors related to the quality of treatment (i.e., active ingredients such as cue-generation) may play an important role in determining treatment efficacy and must also be considered when comparing treatment intensities.

Effects of concurrent action and object naming treatment on naming skills and functional brain activation patterns in primary progressive aphasia: An fMRI study with a case-series design

Individuals with primary progressive aphasia (PPA) exhibit differential impairment patterns in noun and verb naming, but it remains unclear whether anomia treatment results in similar improvements in noun and verb naming. Therefore, we examined the immediate and long-term (3-months post-treatment) behavioral and neural effects of an anomia treatment on object and action naming skills in PPA. A case-series design was utilized involving two individuals with PPA. Object and action words were trained concurrently and probed regularly using word lists matched on a number of lexical characteristics. One participant showed improvements in all word categories with different effect sizes whereas the other participant demonstrated improved naming only on trained object words. Treatment-induced fMRI changes were found in both hemispheres, with distinct patterns observed across participants. Further research is needed to better understand the effects of residual language and cognitive skills on behavioral and neurophysiological outcomes following anomia treatment for PPA.

The Value of Rehabilitation Interventions --Integrating Evidence, Clinical Expertise, Critical Assessment, and , Patient Needs: A Conference Report

In order to understand issues related to value, outcomes, and cost-effectiveness of rehabilitation interventions, and to explore how scientific evidence, clinical expertise, and patient needs can be integrated, the Rehabilitation Research and Training Center on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function held a State of the Science (SOS) Symposium on "The Value of Rehabilitation Interventions" at Shirley Ryan AbilityLab in Chicago in 2017. In this conference, the perspectives of 35 invited experts, including people with disabilities, professionals, and consumers, explored the topic of "value" of rehabilitation interventions and discussed their perspectives on the means to integrate best scientific evidence with clinical expertise and patient preferences. This Symposium also resulted in the production of several multifaceted manuscripts providing perspectives on the topic of value and how to use evidence to best determine and demonstrate it. These papers comprise this Supplement. The present paper introduces the key concepts of value, evidence, and knowledge translation, in an effort to provide a context for the papers of the Supplement.

Intensive and non-intensive treatment of lexical anomia are equally efficient in post-stroke aphasia

Although the treatment for lexical anomia in individuals with aphasia (IWA) was shown effective, little is known about the optimal treatment intensity required. The aim of this study was to verify whether intensive and non-intensive treatments led to different outcomes when parameters of intensity are rigorously controlled. Six IWA with post-stroke lexical anomia received phonological treatment at two distinct frequencies: intensive (four times a week) and non-intensive (once a week). Results showed that both treatments were equally effective. This finding is especially relevant in contexts in which speech-language therapy delivery services are limited.

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.

Variables and Mechanisms Affecting Response to Language Treatment in Multilingual People with Aphasia

BACKGROUND

Despite substantial literature exploring language treatment effects in multilingual people with aphasia (PWA), inconsistent results reported across studies make it difficult to draw firm conclusions.

METHODS

We highlight and illustrate variables that have been implicated in affecting cross-language treatment effects in multilingual PWA.

MAIN CONTRIBUTION

We argue that opposing effects of activation and inhibition across languages, influenced by pertinent variables, such as age of language acquisition, patterns of language use, and treatment-related factors, contribute to the complex picture that has emerged from current studies of treatment in multilingual PWA. We propose a new integrated model-Treatment Effects in Aphasia in Multilingual people (the TEAM model)-to capture this complexity.

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.

An exploration of aphasia therapy dosage in the first six months of stroke recovery

Aphasia research uses the length of time within rehabilitation sessions as the main measure of dosage. Few papers detail therapeutic ingredients or outline the number of times these were delivered over the treatment period. The present observational study identified therapeutic ingredients in the Very Early Rehabiltiation in SpEech (VERSE) trial and explored the dosage provided using a model of cumulative intervention intensity (CII). Therapists video recorded one therapy session per week and 53 (12%) randomly selected therapy videos were analysed. The videos were coded for number of error productions, self-corrections and type and frequency of therapist cueing. The Western Aphasia Battery Revised-Aphasia Quotient (WABR-AQ) was used for measuring patient outcome with total verbal utterances (p < 0.001) and cues used with success (p < 0.001) being independent positive predictors of WABR-AQ score at six months post stroke and hypothesized as key therapeutic ingredients. The CII was calculated by counting identified therapeutic ingredients and multiplying this by the number of sessions completed. Collectively, the key ingredients occurred on average 504 times per session and over 10,000 times per participant during the treatment period. This paper reports a novel approach for identifying key treatment ingredients and detailing the dosage delivered within an early aphasia rehabilitation trial.

Effectiveness of voice therapy in patients with vocal fold nodules: a systematic search and narrative review

BACKGROUND/OBJECTIVE

An adult with vocal fold nodules can suffer from hoarseness, breathiness and vocal fatigue, which, in turn, significantly affects their vocal participation as well as activities. A well-designed voice therapy program improves the quality of life and vocal functionality. This is a narrative review with a systematic search of the current literature about the effectiveness of voice therapy interventions in adults with vocal fold nodules.

METHODS

Several key terms were used for the database electronic search of articles. Strict inclusion criteria were used and a broad evaluation of the studies was performed. This included the level of evidence based on the National Health and Medical Research Council levels of evidence, assessment, and critical appraisal.

RESULTS

Nine out of 30 reviewed articles met the criteria of inclusion and reported positive effects of voice therapy intervention on adult patients with vocal fold nodules. The vast majority of the reviewed studies reported multidimensional voice measures outcome data, most of them containing visual-perceptual, auditory-perceptual, acoustic and self-assessment results. Regardless of receiving direct or indirect or a combination of both voice therapy contents, nearly all voice quality parameters were found to improve after treatment. Short-term treatment (< 3 weeks) may be as beneficial as longer traditional voice therapy programs, and using telepractice voice therapy may be an achievable and practical way of delivering treatment and enhance adherence to therapy. The study design and the evidence levels of the included studies were low (≤ III-2) and the risk of bias of the comparative studies was moderate.

CONCLUSION

This narrative review cannot conclude the general effectiveness of voice therapy programs. Further research and understanding of what specific parameters (exercise and techniques) of a therapy's content will improve voice outcome measures. More studies are required to investigate whether or not voice therapy benefits are sustainable 6 months after ending the therapy. However, improved evidence is required to suggest that short period treatments are as beneficial as traditional therapy programs. Telepractice voice therapy may be an achievable and practical way of delivering treatment and enhance adherence to therapy.

Effects of distributed practice and criterion level on word retrieval in aphasia

This study examined how the distribution and amount of practice affect word retrieval in aphasia as well as how such factors relate to the efficiency of learning. The central hypothesis was that factors that enhance the learning of new knowledge also enhance persistent access to existing, but inconsistently available, word representations. The study evaluated the impact of learning principles on word retrieval by manipulating the timing and amount of retrievals for items presented for naming. Nine people with chronic aphasia with naming impairment completed the experiment. Training materials involved proper noun entities assigned to six conditions formed by crossing a 2-level factor of spacing of sessions, i.e., intersession interval (1 day versus 7 days between sessions) with a 3-level factor of number of correct retrievals per item per session, i.e., criterion level (Criterion-1, Criterion-2, and Criterion-4). Each intersession interval condition comprised three training sessions and a one-month retention test. Increasing the criterion level enhanced naming performance after short (1 day, 7 days) and long (one month) retention intervals, but these advantages came at the cost of many additional training trials. In most cases, later naming success was superior when the same number of correct retrievals of an item was distributed across multiple sessions rather than administered within one session. The substantial advantages for across-session spacing were gained at little cost in terms of additional training trials. At one-month retention, naming accuracy was numerically but not significantly higher in the 7-day versus 1-day intersession interval condition. Implications for theories of lexical access and naming treatment in aphasia are discussed.

Further Study of the Effects of Treatment Intensity on Outcomes of Sound Production Treatment for Acquired Apraxia of Speech: Does Dose Frequency Matter?

Purpose The aim of this study was to examine the effects of dose frequency, an aspect of treatment intensity, on articulation outcomes of sound production treatment (SPT). Method Twelve speakers with apraxia of speech and aphasia received SPT administered with an intense dose frequency and a nonintense/traditional dose frequency (SPT-T). Each participant received both treatment intensities in the context of multiple baseline designs across behaviors. SPT-Intense was provided for 3 hourly sessions per day/3 days per week; and SPT-T for 1 hour-long session per day/3 days per week. Twenty-seven treatment sessions were completed with each phase of treatment. Articulation accuracy was measured in probes of production of treated and untreated words. Results All participants achieved improved articulation of treated words with both intensities; there were no notable differences in magnitude of improvement associated with dose frequency. Positive response generalization to untrained words was found in 21 of 24 treatment applications; the cases of negligible response generalization occurred with SPT-T words. Conclusions Dose frequency (and corresponding total intervention duration) did not appear to impact treatment response for treated items. Disparate response generalization findings for 3 participants in the current study may relate to participant characteristics such as apraxia of speech severity and/or stimuli factors.

A Review of the Application of Distributed Practice Principles to Naming Treatment in Aphasia

It is uncontroversial in psychological research that different schedules of practice, which govern the distribution of practice over time, can promote radically different outcomes in terms of gains in performance and the durability of learning. In contrast, in speech-language treatment research, there is a critical need for well-controlled studies examining the impact of the distribution of treatment on efficacy (for reviews, see Cherney, 2012; Warren, Fey, & Yoder, 2007). In this paper, we enumerate key findings from psychological research on learning and memory regarding how different schedules of practice differentially confer durable learning. We review existing studies of aphasia treatment with a focus on naming impairment that have examined how the distribution of practice affects treatment efficacy. We close by discussing potential productive lines of research to elaborate the clinical applicability of distributed practice principles to language treatment.

Optimising recovery in aphasia: Learning following exposure to a single dose of computer-based script training

Purpose: Intensity of therapy influences outcomes in aphasia treatment, but little is known about optimum dosage across treatment approaches. Improved understanding of the effects of dose could help facilitate clinical decisions that maximise patient outcomes. This study examines learning in individuals with aphasia following exposure to one 60-min dose of computer-delivered script training, with or without a rest break. Method: Twenty participants (6F, 14M; 17 nonfluent, 3 fluent) with chronic aphasia due to left-hemisphere stroke participated. Participants had a mean (SD) age of 56.9 (8.4) years, a mean time post onset of 55.1 (range: 6.4-396.4) months, and a mean (SD) Comprehensive Aphasia Test score of 47.8 (4.0). Participants were exposed to 60 min of training, with or without a rest break, of a three-turn conversational script about either weather or traffic. Treatment was delivered via computer using a virtual clinician that visually modelled speech and guided treatment, promoting treatment fidelity. Oral reading probes for script sentences were administered at baseline (3 times), mid-treatment, immediately post-treatment, and, at various times, up to 2 weeks post-treatment to track script acquisition and maintenance. The study also examined generalisation from a trained script to a conversation with a clinician via a generalisation probe at three time points: baseline, immediately post-treatment, and 2 weeks post-treatment. Result: Following exposure to one dose of script training, participants demonstrated statistically significant improvements in oral reading accuracy and rate of script production on trained probes from baseline to immediately post-treatment and 2 weeks post-treatment. Participants also demonstrated significant change from baseline in generalisation to a conversation with a clinician immediately post-treatment and at 2 weeks post-treatment. Conclusion: Exposure to a single dose of computer-delivered script training may facilitate learning. These results have implications for future research investigating optimal dosage and scheduling parameters.

Treatment for Word Retrieval in Semantic and Logopenic Variants of Primary Progressive Aphasia: Immediate and Long-Term Outcomes

Purpose Recent studies confirm the utility of speech-language intervention in primary progressive aphasia (PPA); however, long-term outcomes, ideal dosage parameters, and relative benefits of intervention across clinical variants warrant additional investigation. The purpose of this study was to determine whether naming treatment affords significant, lasting, and generalized improvement for individuals with semantic and logopenic PPA and whether dosage manipulations significantly affect treatment outcomes. Method Eighteen individuals with PPA (9 semantic and 9 logopenic variant) underwent lexical retrieval treatment designed to leverage spared cognitive-linguistic domains and develop self-cueing strategies to promote naming. One group (n = 10) underwent once-weekly treatment sessions, and the other group (n = 8) received the same treatment with 2 sessions per week and an additional "booster" treatment phase at 3 months post-treatment. Performance on trained and untrained targets/tasks was measured immediately after treatment and at 3, 6, and 12 months post-treatment. Results Outcomes from the full cohort of individuals with PPA showed significantly improved naming of trained items immediately post-treatment and at all follow-up assessments through 1 year. Generalized improvement on untrained items was significant up to 6 months post-treatment. The positive response to treatment was comparable regardless of session frequency or inclusion of a booster phase. Outcomes were comparable across PPA subtypes, as was maintenance of gains over the post-treatment period. Conclusion This study documents positive naming treatment outcomes for a group of individuals with PPA, demonstrating strong direct treatment effects, maintenance of gains up to 1 year post-treatment, and generalization to untrained items. Lexical retrieval treatment, in conjunction with daily home practice, had a strong positive effect that did not require more than 1 clinician-directed treatment session per week. Findings confirm that strategic training designed to capitalize on spared cognitive-linguistic abilities results in significant and lasting improvement, despite ongoing disease progression, in PPA.

Feasibility of Automatic Speech Recognition for Providing Feedback During Tablet-Based Treatment for Apraxia of Speech Plus Aphasia

Purpose Individuals with neurogenic speech disorders require ongoing therapeutic support to achieve functional communication goals. Alternative methods for service delivery, such as tablet-based speech therapy applications, may help bridge the gap and bring therapeutic interventions to the patient in an engaging way. The purpose of this study was to evaluate an iPad-based speech therapy app that uses automatic speech recognition (ASR) software to provide feedback on speech accuracy to determine the ASR's accuracy against human judgment and whether participants' speech improved with this ASR-based feedback. Method Five participants with apraxia of speech plus aphasia secondary to stroke completed an intensive 4-week at-home therapy program using a novel word training app with built-in ASR. Multiple baselines across participants and behaviors designs were employed, with weekly probes and follow-up at 1 month posttreatment. Four sessions a week of 100 practice trials each were prescribed, with 1 being clinician-run and the remainder done independently. Dependent variables of interest were ASR-human agreement on accuracy during practice trials and human-judged word production accuracy over time in probes. Also, user experience surveys were completed immediately posttreatment. Results ASR-human agreement on accuracy averaged ~80%, which is a common threshold applied for interrater agreement. All participants demonstrated improved word production accuracy over time with the ASR-based feedback and maintenance of gains after 1 month. All participants reported enjoying using the app with support of a speech pathologist. Conclusion For these participants with apraxia of speech plus aphasia due to stroke, satisfactory gains were made in word production accuracy with an app-based therapy program providing ASR-based feedback on accuracy. Findings support further testing of this ASR-based approach as a supplement to clinician-run sessions to assist clients with similar profiles in achieving higher amount and intensity of practice as well as empowering them to manage their own therapy program. Supplemental Material https://doi.org/10.23641/asha.8206628.

Retraining speech production and fluency in non-fluent/agrammatic primary progressive aphasia

The non-fluent/agrammatic variant of primary progressive aphasia (nfvPPA) presents with a gradual decline in grammar and motor speech resulting from selective degeneration of speech-language regions in the brain. There has been considerable progress in identifying treatment approaches to remediate language deficits in other primary progressive aphasia variants; however, interventions for the core deficits in nfvPPA have yet to be systematically investigated. Further, the neural mechanisms that support behavioural restitution in the context of neurodegeneration are not well understood. We examined the immediate and long-term benefits of video implemented script training for aphasia (VISTA) in 10 individuals with nfvPPA. The treatment approach involved repeated rehearsal of individualized scripts via structured treatment with a clinician as well as intensive home practice with an audiovisual model using 'speech entrainment'. We evaluated accuracy of script production as well as overall intelligibility and grammaticality for trained and untrained scripts. These measures and standardized test scores were collected at post-treatment and 3-, 6-, and 12-month follow-up visits. Treatment resulted in significant improvement in production of correct, intelligible scripted words for trained topics, a reduction in grammatical errors for trained topics, and an overall increase in intelligibility for trained as well as untrained topics at post-treatment. Follow-up testing revealed maintenance of gains for trained scripts up to 1 year post-treatment on the primary outcome measure. Performance on untrained scripts and standardized tests remained relatively stable during the follow-up period, indicating that treatment helped to stabilize speech and language despite disease progression. To identify neural predictors of responsiveness to intervention, we examined treatment effect sizes relative to grey matter volumes in regions of interest derived from a previously identified speech production network. Regions of significant atrophy within this network included bilateral inferior frontal cortices and supplementary motor area as well as left striatum. Volumes in a left middle/inferior temporal region of interest were significantly correlated with the magnitude of treatment effects. This region, which was relatively spared anatomically in nfvPPA patients, has been implicated in syntactic production as well as visuo-motor facilitation of speech. This is the first group study to document the benefits of behavioural intervention that targets both linguistic and motoric deficits in nfvPPA. Findings indicate that behavioural intervention may result in lasting and generalized improvement of communicative function in individuals with neurodegenerative disease and that the integrity of spared regions within the speech-language network may be an important predictor of treatment response.

Speed-Accuracy Trade-Offs and Adaptation Deficits in Aphasia: Finding the "Sweet Spot" Between Overly Cautious and Incautious Responding

Purpose After stroke, how well do people with aphasia (PWA) adapt to the altered functioning of their language system? When completing a language-dependent task, how well do PWA balance speed and accuracy when the goal is to respond both as quickly and accurately as possible? The current work investigates adaptation theory ( Kolk & Heeschen, 1990 ) in the context of speed-accuracy trade-offs in a lexical decision task. PWA were predicted to set less beneficial speed-accuracy trade-offs than matched controls, and at least some PWA were predicted to present with adaptation deficits, with impaired accuracy or response times attributable to speed-accuracy trade-offs. Method The study used the diffusion model ( Ratcliff, 1978 ), a computational model of response time for simple 2-choice tasks. Parameters of the model can be used to distinguish basic processing efficiency from the overall level of caution in setting response thresholds and were used here to characterize speed-accuracy trade-offs in 20 PWA and matched controls during a lexical decision task. Results Models showed that PWA and matched control groups did not differ overall in how they set response thresholds for speed-accuracy trade-offs. However, case series analyses showed that 40% of the PWA group displayed the predicted adaptation deficits, with impaired accuracy or response time performance directly attributable to overly cautious or overly incautious response thresholds. Conclusions Maladaptive speed-accuracy trade-offs appear to be present in some PWA during lexical decision, leading to adaptation deficits in performance. These adaptation deficits are potentially treatable, and clinical implications and next steps for translational research are discussed.

Acquisition and Generalization Responses in Aphasia Naming Treatment: A Meta-Analysis of Semantic Feature Analysis Outcomes

Purpose This meta-analysis synthesizes results from published studies that used semantic feature analysis (SFA) treatment to improve naming for people with aphasia. It examines how both person- and treatment-related variables affected the likelihood of correct naming responses in individual probe sessions for both acquisition (treated) and generalization (untreated) stimuli. Method The meta-analysis compiled data from 12 studies analyzing a total of 35 participants with aphasia. It used mixed-effects models as a novel statistical tool to examine the effects of 2 sets of variables on naming performance: treatment-related variables, including treatment phase (baseline vs. treatment), dosage (number of treatment sessions), and stimulus type (treated vs. untreated, semantically related vs. unrelated items), and person-specific variables, including degree of language impairment and demographic variables (age, time poststroke). Results Results of the meta-analysis revealed that SFA intervention promoted increased naming accuracy during naming probes when comparing baseline and treatment phases. In addition, increased dosages of SFA were associated with increased naming accuracy, and treatment-related gains were larger for acquisition (treated) than generalization (untreated) stimuli, likewise for related versus unrelated generalization stimuli. Furthermore, a subset of person-specific variables was predictive of SFA-related gains: Language impairment variables were related to treatment-related changes in naming performance, but demographic variables were not. Conclusion These results provide group-level evidence for the efficacy of SFA as well as preliminary estimates of how much naming performance benefit is engendered by varying dosages of SFA. The results also provide promising and previously unobserved evidence of potential person-level predictors of SFA treatment response.

Script Training Using Telepractice with Two Adults with Chronic Non-Fluent Aphasia

Two male participants with chronic (> 2 years), non-fluent aphasia and their family members participated in script training using videoconferencing. Functional scripts were developed by people with aphasia (PWA) and their family members. Accuracy of scripts was measured by total target words produced per turn. Participant 1 with Broca’s aphasia produced scripts with 0% accuracy pre-treatment and 87.5% accuracy post-treatment. Participant 2 with Transcortical Motor aphasia produced scripts with 20.2% accuracy pre-treatment and 63.5% accuracy post-treatment. Pre- and post-questionnaires for communication effectiveness and the use of telepractice for speech therapy indicated improvements in answering yes/no questions, participating in conversations with strangers, and increasing confidence and satisfaction with technology delivered treatment. The use of videoconferencing to deliver script training appears beneficial for individuals with chronic aphasia.

Treatment Response to a Double Administration of Constraint-Induced Language Therapy in Chronic Aphasia

Purpose

This study investigated changes in oral-verbal expressive language associated with improvements following 2 treatment periods of constraint-induced language therapy in 4 participants with stroke-induced chronic aphasia. Generalization of treatment to untrained materials and to discourse production was also analyzed, as was the durability of the treatment effect.

Method

Participants with aphasia were assessed using standardized measures and discourse tasks at 3 to 4 time points to document behavioral changes throughout each of two 30-hr treatment periods of constraint-induced language therapy. Daily probes of trained and untrained materials were also administered.

Results

Despite participant heterogeneity, behavioral results for each person with aphasia indicated a positive response to treatment following each treatment period indicated by performance on standardized tests, trained materials, or both. Treatment effects generalized to some degree to untrained stimuli and to discourse measures and were generally maintained at follow-up testing.

Conclusions

Data support the utility of a 2nd treatment period. Results are relevant to rehabilitation in chronic aphasia, confirming that significant language gains continue well past the point of spontaneous recovery and can occur in a relatively short time period. Importantly, changes are not confined to a single treatment period, suggesting that people with aphasia may benefit from multiple doses of high-intensity treatment.

What Matters in Semantic Feature Analysis: Practice-Related Predictors of Treatment Response in Aphasia

PURPOSE

This study investigated the predictive value of practice-related variables-number of treatment trials delivered, total treatment time, average number of trials per hour, and average number of participant-generated features per trial-in response to semantic feature analysis (SFA) treatment.

METHOD

SFA was administered to 17 participants with chronic aphasia daily for 4 weeks. Individualized treatment and semantically related probe lists were generated from items that participants were unable to name consistently during baseline testing. Treatment was administered to each list sequentially in a multiple-baseline design. Naming accuracy for treated and untreated items was obtained at study entry, exit, and 1-month follow-up.

RESULTS

Item-level naming accuracy was analyzed using logistic mixed-effect regression models. The average number of features generated per trial positively predicted naming accuracy for both treated and untreated items, at exit and follow-up. In contrast, total treatment time and average trials per hour did not significantly predict treatment response. The predictive effect of number of treatment trials on naming accuracy trended toward significance at exit, although this relationship held for treated items only.

CONCLUSIONS

These results suggest that the number of patient-generated features may be more strongly associated with SFA-related naming outcomes, particularly generalization and maintenance, than other practice-related variables.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5734113.

An update on medications and noninvasive brain stimulation to augment language rehabilitation in post-stroke aphasia

INTRODUCTION

Aphasia is among the most debilitating outcomes of stroke. Aphasia is a language disorder occurring in 10-30% of stroke survivors. Speech and Language Therapy (SLT) is the gold standard, mainstay treatment for aphasia, but gains from SLT may be incomplete. Pharmaceutical and noninvasive brain stimulation (NIBS) techniques may augment the effectiveness of SLT. Areas covered: Herein reviewed are studies of the safety and efficacy of these adjunctive interventions for aphasia, including randomized placebo-controlled and open-label trials, as well as case series from Pubmed, using search terms 'pharmacological,' 'tDCS' or 'TMS' combined with 'aphasia' and 'stroke.' Expert commentary: Relatively small studies have included participants with a range of aphasia types and severities, using inconsistent interventions and outcome measures. Results to-date have provided promising, but weak to moderate evidence that medications and/or NIBS can augment the effects of SLT for improving language outcomes. We end with recommendations for future approaches to studying these interventions, with multicenter, double-blind, randomized controlled trials.

Constraint Induced Aphasia Therapy: Volunteer-led, unconstrained and less intense delivery can be effective

BACKGROUND

Constraint Induced Aphasia Therapy (CIAT) has been shown to be effective in the treatment of aphasia, but clinicians have expressed concern regarding how far CIAT is practical to implement in clinical practice.

OBJECTIVE

To determine whether CIAT delivered in a less-intense, lower dose, reduced constraint and volunteer-led format could produce positive outcomes in people with chronic aphasia.

METHODS

Two groups were run, each with two people with chronic aphasia. Treatment involved a standard CIAT card-exchange game, supplemented by a home activity. Spoken language was required for responses but alternative modalities of communication were also permitted. Each group was led by a trained volunteer, lasted 90 minutes and was delivered twice a week for four weeks.

RESULTS

Three of the four participants showed significant improvements in target word retrieval following treatment. No significant improvements were observed for untreated stimuli or language tasks. Two participants showed increases in the elaboration of their responses, and the same two showed an increase in the frequency with which they engaged in communication activities.

CONCLUSIONS

Clear gains in performance were observed for the majority of people with aphasia who participated in a less intense format, considerably lower dose and less constrained form of CIAT led by trained volunteers. This suggests that this 'clinically realistic' service delivery model for CIAT could be added to the clinical repertoire of speech pathologists.

The Influence of Speech-Language-Hearing Therapy Duration on the Degree of Improvement in Poststroke Language Impairment

Background. The relevance of speech-language-hearing therapy (ST) duration to language impairment remains unclear. Objective. To determine the effect of ST duration on improvement in language impairment as a stroke sequela and to compare the findings with those for occupational therapy (OT) and physical therapy (PT). Methods. Data regarding patients with stroke sequelae who were registered in the Japanese Association of Rehabilitation Medicine database were analyzed. Propensity scores for ST, OT, and PT duration were calculated using logistic regression, followed by inverse probability weighting in generalized estimating equations to examine the odds ratio for improvement in the Functional Independence Measures scores for comprehension, expression, and memory. Analyses stratified by age and dementia severity were also conducted. Results. Compared with short-duration ST, long-duration ST was significantly associated with improved scores for comprehension and expression in the overall study population and in some groups, with higher benefit especially for younger participants (<64 years) and those with more severe dementia. A significant but less pronounced effect was also observed for OT and PT. Conclusion. Long-duration ST is more effective than long-duration OT or PT for improving language impairment occurring as stroke sequela. However, these effects are limited by age and severity of dementia.

The Use of One or Three Semantic Associative Primes in Treating Anomia in Aphasia

PURPOSE

The aims of the study were to investigate the use of semantic associative relationships as primes in treating naming deficits, or anomia, in aphasia and to determine if differential treatment effects would be found if 1 or 3 primes were presented.

METHOD

Ten individuals with varying degrees of anomia participated in the study. A single-subject, A-B treatment design with a cross-over component was used. A 1-PRIME condition (use of 1 prime) was compared with a 3-PRIMES condition (use of 3 primes) for each participant.

RESULTS

Visual analyses of treatment data revealed improvements in 8 of 10 participants. Meaningful effect sizes were obtained in at least 1 of the conditions for 6 of the 10 participants. Slightly more participants demonstrated meaningful effect sizes in the 3-PRIMES condition than in the 1-PRIME condition. Correlation analyses revealed a positive correlation between the number of teaching episodes and 3-PRIMES probe performance.

CONCLUSIONS

The results support a protocol that uses semantic associative primes to increase naming accuracy in aphasia. The 3-PRIMES condition was slightly more beneficial than the 1-PRIME condition in terms of improving naming abilities in these participants, but there was no overwhelming advantage in using one or the other condition.

Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint

Purpose

Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical.

Method

Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality.

Results

All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant.

Conclusion

Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Feature rich, but user-friendly: Speech pathologists' preferences for computer-based aphasia therapy

PURPOSE

High-intensity language therapy has been shown to provide greater outcomes for people with aphasia (PWA). Unfortunately, a number of issues including the ageing population and a lack of rurally-based clinicians prevent high-intensity interventions. Computer-based therapies are a potential solution to the issues of intensity and accessibility; however, this service delivery model is not commonly used. A possible reason behind the poor uptake is that current computer-based aphasia therapy (CBAT) programs may not meet the needs of speech-language pathologists (SLPs). This study investigated the preferences of SLPs with regard to the features desired in their ideal CBAT program.

METHOD

Phenomenological research methodology was used to explore the preferences of 10 SLPs. Data were analysed using qualitative thematic analysis.

RESULT

Desired features were grouped into five themes: therapy activities, stimuli, cues, access and progress data. A range of sub-themes were also identified.

CONCLUSION

The wide range of desirable features found in this study may reflect the extent to which current CBAT programs are considered to be useful, but perhaps do not meet the needs of users. The study's findings provide useful information for future CBAT developers to create programs with high clinician usability.

Increasing aphasia treatment intensity in an acute inpatient rehabilitation program: A feasibility study

BACKGROUND

Intensity of therapy is a critical factor influencing outcomes in aphasia. However, there are many barriers to increasing treatment intensity for those with acute/subacute aphasia including the demands of the inpatient medical facilities and the endurance of the participants. Nevertheless, with some modifications to its original procedures, evidence suggests that Constraint Induced Language Therapy (CILT) may yield positive outcomes when given in the early stages of recovery.

AIMS

To investigate the feasibility of increasing the amount of therapy provided to individuals with aphasia on an inpatient rehabilitation unit by adding CILT at a modified intensity, and to assess whether those receiving two weeks of the additional CILT show more improvement than control participants who did not receive the additional treatment.

METHODS AND PROCEDURES

A case-series single-subject design study was conducted. All participants received usual care of approximately an hour of speech and language treatment, five to six days a week. Participants in the experimental condition received an additional hour-long CILT session, five days per week, for two weeks. Trained, untrained, and generalization probes comprising naming of pictured items and oral reading of sentences were taken at baseline, during treatment, and at post-treatment. All participants were probed equally. Probe performance was scored and effect sizes were calculated and compared. Performance gains from pre- to post-treatment on subtests of the Boston Diagnostic Aphasia Examination were also compared.

OUTCOMES AND RESULTS

Thirteen individuals with aphasia onset ranging from 7 to 68 days were recruited, with 6 allocated to the experimental Usual Care + CILT condition and 7 allocated to the control Usual Care condition. Increasing the amount of speech and language therapy by adding an hour of daily CILT was feasible. Individual performance varied within and across conditions with large gains noted in some, but not all participants. As a group, there was a small to medium effect size of the Usual Care + CILT condition over Usual Care alone for trained and untrained oral reading probes and untrained naming probes.

CONCLUSIONS

It is feasible to increase the amount of treatment provided to participants with aphasia on an acute inpatient rehabilitation unit. Preliminary results suggest that there may be better outcomes for those who receive more treatment. Further research using larger numbers of homogeneous participants and controlling for content of therapy as well as amount of therapy is warranted.

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

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

The impact of dose on naming accuracy with persons with aphasia

BACKGROUND

Although aphasia rehabilitation has been shown to be efficacious, many questions remain regarding how best to deliver treatment to maximize functional gains for persons with aphasia. Treatment delivery variables, such as intensity and dosage, are likely to influence both behavioral and structural changes during anomia treatment. While numerous protocols have concluded that treatment intensity positively impacts functional outcomes, few studies to date have examined the role that dose plays in patient outcomes for anomia treatment.

AIMS

This study sought to investigate how manipulating dose of repeated confrontation naming within sessions influences naming in persons with aphasia. Repeated practice of confrontation naming, without feedback, was hypothesized to improve trained but not untrained words, to be persistent after withdrawal, and to be sensitive to the number of trials (i.e., dose) within sessions.

METHODS AND PROCEDURES

A single-subject ABA design with replication across seven participants with aphasia was used to investigate the influence of repeated confrontation naming attempts on the acquisition and maintenance of trained pictures relative to untrained pictures. Training involved repeated attempts to name pictures, along with repeated exposure to pictures of objects (nouns) and their names, without feedback. The primary independent variable was within session dose; the dependent variable was naming accuracy.

OUTCOMES AND RESULTS

Naming accuracy improved for all participants for trained pictures across both acquisition and maintenance phases per visual inspection; such positive effects were not observed for untrained pictures. Effect size calculations indicate that three of seven participants demonstrated considerable change for trained items, while one of seven participants demonstrated meaningful change for untrained items. The high-dose condition elicited small effect sizes for one participant, and large effect sizes for two of seven participants, while the low-dose condition elicited small and medium effect sizes for two of seven participants.

CONCLUSIONS

Participants across a variety of aphasia severity levels responded positively to two doses of repeated confrontation naming practice, without feedback, across phases of this naming protocol. Results are in line with principles of neuroplasticity and demonstrate that repeated practice, without feedback, can produce significant and persistent changes in naming ability for some persons with aphasia.

A compensatory role for declarative memory in neurodevelopmental disorders

Most research on neurodevelopmental disorders has focused on their abnormalities. However, what remains intact may also be important. Increasing evidence suggests that declarative memory, a critical learning and memory system in the brain, remains largely functional in a number of neurodevelopmental disorders. Because declarative memory remains functional in these disorders, and because it can learn and retain numerous types of information, functions, and tasks, this system should be able to play compensatory roles for multiple types of impairments across the disorders. Here, we examine this hypothesis for specific language impairment, dyslexia, autism spectrum disorder, Tourette syndrome, and obsessive-compulsive disorder. We lay out specific predictions for the hypothesis and review existing behavioral, electrophysiological, and neuroimaging evidence. Overall, the evidence suggests that declarative memory indeed plays compensatory roles for a range of impairments across all five disorders. Finally, we discuss diagnostic, therapeutic and other implications.