Combining rTMS With Intensive Language-Action Therapy in Chronic Aphasia: A Randomized Controlled Trial

Synergistic effects of combined motor and language interventions on stroke rehabilitation: a holistic approach

Background

Stroke patients typically suffer from a range of symptoms, such as motor and language impairments, due to shared neural networks. The recovery process after stroke is intricate and requires a comprehensive approach. While previous studies have investigated the motor and language interventions independently, this study aimed to explore the relationship between these domains and compared the effectiveness of individual interventions versus their combined use.

Methods

We divided 45 stroke patients into three groups: Speech and Language Therapy (SLT) group; Arm Ability Training (AAT) group; and consecutive combination of SLT and AAT group. Participants attended 40-min sessions three days a week for three weeks. Standardized assessments, including picture naming test, syntactic comprehension test, and Test d'Evaluation des Membres Supérieurs de Personnes Âgées (TEMPA) test, were conducted pre-and post-treatment and during the first and second weeks of the intervention.

Results

Within-group comparisons demonstrated a significant enhancement in test scores for all groups post-intervention compared to pre-intervention (p < 0.05). Between-group comparisons revealed significant differences (p < 0.05) in performance on the picture naming test during the first week, the syntactic comprehension test in the second week, the functional rating subscale of Tempa test changes pre-and post-treatment and the first week, and the length of the time subscale of Tempa test improvements from pre-intervention to the first week.

Conclusion

Findings underscored the mutual and synergistic benefits of integrating motor and language in stroke rehabilitation. While SLT and AAT were effective when applied independently, their combined application yielded superior outcomes, emphasizing the holistic advantages of integrating these interventions, as supported by existing literature on dual-task rehabilitation strategies.

Clinical trial registration

https://irct.behdasht.gov.ir/search/result?query=IRCT20200114046134N1, IRCT20200114046134N1.

Global research trends in transcranial magnetic stimulation for stroke (1994-2023): promising, yet requiring further practice

Background

Scholars have been committed to investigating stroke rehabilitation strategies over many years. Since its invention, transcranial magnetic stimulation (TMS) has been increasingly employed in contemporary stroke rehabilitation research. Evidence has shown the significant potential of TMS in stroke research and treatment.

Objective

This article reviews the research conducted on the use of TMS in stroke from 1994 to 2023. This study applied bibliometric analysis to delineate the current research landscape and to anticipate future research hotspots.

Method

The study utilized the Web of Science Core Collection to retrieve and acquire literature data. Various software tools, including VOSviewer (version 1.6.19), CiteSpace (version 6.3.R1), Scimago Graphica (version 1.0.36), and WPS (version 11572), were used for data analysis and visualization. The review included analyses of countries, institutions, authors, journals, articles, and keywords.

Results

A total of 3,425 articles were collected. The top three countries in terms of publication output were the United States (953 articles), China (546 articles), and Germany (424 articles). The United States also had the highest citation counts (56,764 citations), followed by Germany (35,211 citations) and the United Kingdom (32,383 citations). The top three institutions based on the number of publications were Harvard University with 138 articles, the University of Auckland with 81 articles, and University College London with 80 articles. The most prolific authors were Abo, Masahiro with 54 articles, Fregni, Felipe with 53 articles, and Pascual-Leone, Alvaro with 50 articles. The top three journals in terms of article count were Neurorehabilitation and Neural Repair with 139 articles, Clinical Neurophysiology with 128 articles, and Frontiers in Neurology with 110 articles. The most frequently occurring keywords were stroke (1,275 occurrences), transcranial magnetic stimulation (1,119 occurrences), and rehabilitation (420 occurrences).

Conclusion

The application of TMS in stroke research is rapidly gaining momentum, with the USA leading in publications. Prominent institutions, such as Harvard University and University College London, show potential for collaborative research. The key areas of focus include post-stroke cognitive impairment, aphasia, and dysphagia, which are expected to remain significant hotspots in future research. Future research should involve large-scale, randomized, and controlled trials in these fields. Additionally, identifying more effective combined therapies with rTMS should be a priority.

Repetitive Transcranial Magnetic Stimulation for Action Naming in Aphasia Rehabilitation: A Systematic Review and Meta-Analysis

Anomia, characterized by difficulty in word retrieval, particularly action verbs, poses a significant challenge in post-stroke aphasia. Repetitive transcranial magnetic stimulation (rTMS) has gained attention for language processing investigations and interventions. This systematic review explores the potential of rTMS as a modality to address action-verb deficits in post-stroke aphasia. We searched MEDLINE via PubMed, CINAHL via Ebsco and Web of Science in February 2024 for English articles (1996-2024). Eligible studies involved post-stroke aphasia action naming rehabilitation with rTMS. In some of these studies, rTMS was combined with speech-language therapy. In total, 10 studies were included in this systematic review. These articles highlight the potential of rTMS in improving verb retrieval deficits. While significant improvements may not be evident, notable progress both before and after intervention is observed in this review. However, it also underscores the need for further research to enhance language recovery for individuals with post-stroke aphasia.

Inclusion of People With Aphasia in Stroke Trials: A Systematic Search and Review

BACKGROUND

Although people with aphasia (PwA) represent 30% of stroke survivors, they are frequently excluded from stroke research, or their inclusion is unclear. Such practice significantly limits the generalizability of stroke research, increases the need to duplicate research in aphasia-specific populations, and raises important ethical and human rights issues.

OBJECTIVE

To detail the extent and nature of inclusion of PwA in contemporary stroke randomized controlled trials (RCTs).

METHODS

We conducted a systematic search to identify completed stroke RCTs and RCT protocols published in 2019. Web of Science was searched using terms "stroke" and "randomized controlled trial". These articles were reviewed by extracting rates of PwA inclusion/exclusion, whether "aphasia" or related terms were referred to in the article or supplemental files, eligibility criteria, consent procedures, adaptations made to support the inclusion of PwA, and attrition rates of PwA. Data were summarized, and descriptive statistics applied when appropriate.

RESULTS

271 studies comprising 215 completed RCTs and 56 protocols were included. 36.2% of included studies referred to aphasia/dysphasia. Of completed RCTs, only 6.5% explicitly included PwA, 4.7% explicitly excluded PwA, and inclusion was unclear in the remaining 88.8%. Among RCT protocols, 28.6% of studies intended inclusion, 10.7% intended excluding PwA, and in 60.7%, inclusion was unclear. In 45.8% of included studies, sub-groups of PwA were excluded, either explicitly (ie, particular types/severities of aphasia, eg, global aphasia) or implicitly, by way of ambiguous eligibility criteria which could potentially relate to a sub-group of PwA. Little rationale for exclusion was provided. 71.2% of completed RCTs did not report any adaptations that could support the inclusion of PwA, and minimal information was provided about consent procedures. Where it could be determined, attrition of PwA averaged 10% (range 0%-20%).

CONCLUSION

This paper details the extent of inclusion of PwA in stroke research and highlights opportunities for improvement.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

Effect and safety of C7 neurotomy at the intervertebral foramen in patients with chronic poststroke aphasia: a multicentre, randomised, controlled study protocol

INTRODUCTION

Aphasia affects many stroke survivors; therefore, effective treatments are urgently needed. Preliminary clinical findings have suggested an association between contralateral C7-C7 cross nerve transfer and recovery from chronic aphasia. Randomised controlled trials supporting the efficacy of C7 neurotomy (NC7) are lacking. This study will explore the efficacy of NC7 at the intervertebral foramen for improving chronic poststroke aphasia.

METHODS AND ANALYSIS

This study protocol reports a multicentre, randomised, assessor-blinded active-controlled trial. A total of 50 patients with chronic poststroke aphasia for over 1 year and with a aphasia quotient calculated by Western Aphasia Battery Aphasia Quotient (WAB-AQ) score below 93.8 will be recruited. Participants will be randomly assigned to 1 of 2 groups (25 individuals each) to receive NC7 plus intensive speech and language therapy (iSLT), or iSLT alone programme. The primary outcome is the change in Boston Naming Test score from baseline to the first follow-up after NC7 plus 3 weeks of iSLT or iSLT alone. The secondary outcomes include the changes in the WAB-AQ, Communication Activities of Daily Living-3, International Classification of Functioning, Disability and Health (ICF) speech language function, Barthel Index, Stroke Aphasic Depression Questionnaire-hospital version and sensorimotor assessments. The study will also collect functional imaging outcomes of naming and semantic violation tasks through functional MRI and electroencephalogram to evaluate the intervention-induced neuroplasticity.

ETHICS AND DISSEMINATION

This study was approved by the institutional review boards of Huashan Hospital, Fudan University, and all participating institutions. The study findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200057180.

People with aphasia and their family members proposing joint future activities in everyday conversations: A conversation analytic study

BACKGROUND

In everyday conversations, a person with aphasia (PWA) compensates for their language impairment by relying on multimodal and material resources, as well as on their conversation partners. However, some social actions people perform in authentic interaction, proposing a joint future activity, for example, ordinarily rely on a speaker producing a multi-word utterance. Thus, the language impairment connected to aphasia may impede the production of such proposals, consequently hindering the participation of PWAs in the planning of future activities.

AIMS

To investigate (1) how people with post-stroke chronic aphasia construct proposals of joint future activities in everyday conversations compared with their familiar conversation partners (FCPs); and (2) how aphasia severity impacts on such proposals and their uptake.

METHODS & PROCEDURES

Ten hours of video-recorded everyday conversations from seven persons with mild and severe aphasia of varying subtypes and their FCPs were explored using conversation analysis. We identified 59 instances where either party proposed a joint future activity and grouped such proposals according to their linguistic format and sequential position. Data are in Finnish.

OUTCOMES & RESULTS

People with mild aphasia made about the same number of proposals as their FCPs and used similar linguistic formats to their FCPs when proposing joint future activities. This included comparable patterns associated with producing a time reference, which was routinely used when a proposal initiated a planning activity. Mild aphasia manifested itself as within-turn word searches that were typically self-repaired. In contrast, people with severe aphasia made considerably fewer proposals compared with their FCPs, the proposal formats being linguistically unidentifiable. This resulted in delayed acknowledgement of the PWAs' talk as a proposal.

CONCLUSIONS & IMPLICATIONS

Mild aphasia appears not to impede PWAs' ability to participate in the planning of joint future activities, whereas severe aphasia is a potential limitation. To address this possible participatory barrier, we discuss clinical implications for both therapist-led aphasia treatment and conversation partner training.

WHAT THIS PAPER ADDS

What is already known on the subject PWAs use multimodal resources to compensate for their language impairment in everyday conversations. However, certain social actions, such as proposing a joint future activity, cannot ordinarily be accomplished without language. What this paper adds to existing knowledge The study demonstrates that proposing joint future activities is a common social action in everyday conversations between PWAs and their family members. People with mild aphasia used typical linguistic proposal formats, and aphasic word-finding problems did not prevent FCPs from understanding the talk as a proposal. People with severe aphasia constructed proposals infrequently using their remaining linguistic resources, a newspaper connecting the talk to the future and the support from FCPs. What are the potential or actual clinical implications of this work? We suggest designing aphasia treatment with reference to the social action of proposing a joint future activity. Therapist-led treatment could model typical linguistic proposal formats, whereas communication partner training could incorporate FCP strategies that scaffold PWAs' opportunities to construct proposals of joint future activities. This would enhance aphasia treatment's ecological validity, promote its generalization and ultimately enable PWAs to participate in everyday planning activities.

Continuous theta burst stimulation-induced suppression of the right fronto-thalamic-cerebellar circuit accompanies improvement in language performance in poststroke aphasia: A resting-state fMRI study

Background

Continuous theta burst stimulation (cTBS) is a specific paradigm of repetitive transcranial magnetic stimulation (rTMS) with an inhibitory effect on cortical excitability for up to 60 min after less than 1 min of stimulation. The right posterior superior temporal gyrus (pSTG), homotopic to Wernicke's area in the left hemisphere, may be a potential stimulation target based on its critical role in semantic processing. The objective of this study was to explore whether cTBS over the right pSTG can promote language improvements in aphasic patients and the underlying mechanism.

Methods

A total of 34 subjects with aphasia were randomly assigned to undergo 15 sessions of either 40-s inhibitory cTBS over the right pSTG (the cTBS group) or sham stimulation (the sham group), followed by 30 min of speech and language therapy. Subjects underwent resting-state functional magnetic resonance imaging (rs-fMRI), and the aphasia quotient (AQ) of the Chinese version of the Western Aphasia Battery (WAB) was calculated before and after the intervention. This randomized controlled trial was registered in the Chinese Clinical Trial Registry (No. ChiCTR210052962).

Results

After treatment, the language performance of the cTBS group was higher than that of the sham group in terms of the WAB-AQ score (p = 0.010) and the WAB scores for auditory comprehension (p = 0.022) and repetition (p = 0.035). The fractional amplitude of low-frequency fluctuations (fALFF) was significantly decreased in the pars triangularis of the inferior frontal gyrus (IFG), right middle frontal gyrus, right thalamus, and left cerebellar crus I. Clusters in the left orbitofrontal cortex exhibited increased fALFF. The change in WAB comprehension scores were significantly correlated with the change in the fALFF of the right IFG pars triangularis in both groups. Greatly increased functional connectivity was observed between the right pars triangularis and left paracingulate gyrus and between the right pSTG and right angular gyrus and the posterior cingulate gyrus with pre-and post-treatment between the two groups.

Conclusion

Our findings indicate that cTBS of the right pSTG may improve language production by suppressing intrinsic activity of the right fronto-thalamic-cerebellar circuit and enhancing the involvement of the right temporoparietal region.

Targeted neurorehabilitation strategies in post-stroke aphasia

BACKGROUND

Aphasia is a debilitating language impairment, affecting millions of people worldwide. About 40% of stroke survivors develop chronic aphasia, resulting in life-long disability.

OBJECTIVE

This review examines extrinsic and intrinsic neuromodulation techniques, aimed at enhancing the effects of speech and language therapies in stroke survivors with aphasia.

METHODS

We discuss the available evidence supporting the use of transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation, and functional MRI (fMRI) real-time neurofeedback in aphasia rehabilitation.

RESULTS

This review systematically evaluates studies focusing on efficacy and implementation of specialized methods for post-treatment outcome optimization and transfer to functional skills. It considers stimulation target determination and various targeting approaches. The translation of neuromodulation interventions to clinical practice is explored, emphasizing generalization and functional communication. The review also covers real-time fMRI neurofeedback, discussing current evidence for efficacy and essential implementation parameters. Finally, we address future directions for neuromodulation research in aphasia.

CONCLUSIONS

This comprehensive review aims to serve as a resource for a broad audience of researchers and clinicians interested in incorporating neuromodulation for advancing aphasia care.

Repetitive Transcranial Magnetic Stimulation in Post-stroke Aphasia: Comparative Evaluation of Inhibitory and Excitatory Therapeutic Protocols: Narrative Review

OBJECTIVE

Aphasia is a serious consequence of stroke resulting in difficulties in using language for communication with negative effects on patients' quality of life. The use of non-invasive repetitive transcranial magnetic stimulation (rTMS) is a novel approach in aphasia therapy, based on the knowledge gained by functional imaging technics of the brain.

AIM

This review evaluates the effectiveness of rTMS on aphasia therapy according to the results of English language studies that have been published in the databases PubMed/Medline, Scopus, and Web of Science from 2011 to 2021.

RESULTS

Twenty-seven studies were included in the review with 672 participants. The studies mainly concern the application of inhibitory rTMS on the right inferior frontal gyrus (rIFG) in the subacute and chronic phase, as well as excitatory rTMS of the unaffected language areas of the left cerebral hemisphere in the chronic phase after stroke. Most of the studies concluded that there was statistically significant improvement in various parameters of language including confrontation naming, repetition, and aphasia quotient. Three studies published results that doubt the effectiveness of rTMS.

CONCLUSION

rTMS is a safe therapeutic method for aphasia treatment in the subacute and chronic phases after stroke. Its effectiveness is immediate as well as distant with a gradually decreasing therapeutic effect. Moreover, rTMS may supplement speech and language therapy as a priming factor. The most recognized method at this point in time is the application of suppressive rTMS on the right inferior frontal gyrus in combination with speech and language therapy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cerebellar Continuous Theta Burst Stimulation for Aphasia Rehabilitation: Study Protocol for a Randomized Controlled Trial

Background

Language recovery is limited in moderate to severe post-stroke aphasia patients. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising tool in improving language dysfunctions caused by post-stroke aphasia, but the treatment outcome is as yet mixed. Considerable evidence has demonstrated the essential involvement of the cerebellum in a variety of language functions, suggesting that it may be a potential stimulation target of TMS for the treatment of post-stroke aphasia. Theta burst stimulation (TBS) is a specific pattern of rTMS with shorter stimulation times and better therapeutic effects. The effect of continuous TBS (cTBS) on the cerebellum in patients with aphasia with chronic stroke needs further exploration.

Methods

In this randomized, sham-controlled clinical trial, patients (n = 40) with chronic post-stroke aphasia received 10 sessions of real cTBS (n = 20) or sham cTBS (n = 20) over the right cerebellar Crus I+ a 30-min speech-language therapy. The Western Aphasia Battery (WAB) serves as the primary measure of the treatment outcome. The secondary outcome measures include the Boston Diagnostic Aphasia Examination, Boston Naming Test and speech acoustic parameters. Resting-state fMRI data were also obtained to examine treatment-induced changes in functional connectivity of the cerebro-cerebellar network. These outcome measures are assessed before, immediately after, and 12 weeks after cerebellar cTBS intervention.

Discussion

This protocol holds promise that cerebellar cTBS is a potential strategy to improve language functions in chronic post-stroke aphasia. The resting-state fMRI may explore the neural mechanism underlying the aphasia rehabilitation with cerebellar cTBS.

The multidimensional nature of aphasia recovery post-stroke

Language is not a single function, but instead results from interactions between neural representations and computations that can be damaged independently of each other. Although there is now clear evidence that the language profile in post-stroke aphasia reflects graded variations along multiple underlying dimensions ('components'), it is still entirely unknown if these distinct language components have different recovery trajectories and rely on the same, or different, neural regions during aphasia recovery. Accordingly, this study examined whether language components in the subacute stage: (i) mirror those observed in the chronic stage; (ii) recover together in a homogeneous manner; and (iii) have recovery trajectories that relate to changing activation in distinct or overlapping underlying brain regions. We analysed longitudinal data from 26 individuals with mild-moderate aphasia following left hemispheric infarct who underwent functional MRI and behavioural testing at ∼2 weeks and ∼4 months post-stroke. The language profiles in early post-stroke aphasia reflected three orthogonal principal components consisting of fluency, semantic/executive function and phonology. These components did not recover in a singular, homogeneous manner; rather, their longitudinal trajectories were uncorrelated, suggesting that aphasia recovery is heterogeneous and multidimensional. Mean regional brain activation during overt speech production in unlesioned areas was compared with patient scores on the three principal components of language at both the early and late time points. In addition, the change in brain activation over time was compared with the change on each of the principal component scores, both before and after controlling for baseline scores. We found that different language components were associated with changing activation in multiple, non-overlapping bilateral brain regions during aphasia recovery. Specifically, fluency recovery was associated with increasing activation in bilateral middle frontal gyri and right temporo-occipital middle temporal gyrus; semantic/executive recovery was associated with reducing activation in bilateral anterior temporal lobes; while phonology recovery was associated with reducing activation in bilateral precentral gyri, dorso-medial frontal poles and the precuneus. Overlapping clusters in the ventromedial prefrontal cortex were positively associated with fluency recovery but negatively associated with semantic/executive and phonology recovery. This combination of detailed behavioural and functional MRI data provides novel insights into the neural basis of aphasia recovery. Because different aspects of language seem to rely on different neural regions for recovery, treatment strategies that target the same neural region in all stroke survivors with aphasia might be entirely ineffective or even impair recovery, depending on the specific language profile of each individual patient.

Combining electroacupuncture and transcranial direct current stimulation as an adjuvant therapy enhances spontaneous conversation and naming in subacute vascular aphasia: A retrospective analysis

OBJECTIVE

Emerging evidence shows the effectiveness of speech and language therapy (SLT); however, precise therapeutic parameters remain unclear. Evidence for the use of adjunctive transcranial direct current stimulation (tDCS) to treat post-stroke aphasia (PSA) is promising; however, the utility of combining tDCS and electroacupuncture (EA) has not yet been analyzed. This study assessed the therapeutic consequences of EA and tDCS coupled with SLT in subacute PSA patients who were also undergoing hyperbaric oxygen therapy (HBOT).

METHODS

A retrospective analysis was conducted on subacute (< 6 months) PSA patients who were divided into three groups: patients who received EA plus tDCS (acupuncture group), patients who underwent tDCS (tDCS group), and patients who experienced conventional therapy (HBOT + SLT). All subjects underwent 21 days of treatment and also received conventional treatment. The aphasia battery of Chinese (ABC) was used to score pre- and post-intervention status.

RESULTS

The analysis comprised 238 patients. Cerebral infarction was the most frequent stroke type (137 [57.6%]), while motor (66 [27.7%]) and global aphasia (60 [25.2%]) were the most common types of aphasia. After 21 days of intervention, the ABC scores of all patients were improved. The acupuncture group had the highest ABC scores, but only repetition, naming, and spontaneous speech were statistically improved (P < 0.01). Post-hoc tests revealed significant improvement in word retrieval in the acupuncture and tDCS groups (P < 0.01, P = 0.037), while the acupuncture group had additional significant improvement in spontaneous conversation (P < 0.01).

CONCLUSION

Combining acupuncture and tDCS as an adjuvant therapy for subacute PSA led to significant spontaneous speech and word retrieval improvements. Future prospective, multi-ethnic, multi-center trials are warranted.

Noninvasive brain stimulation to augment language therapy for poststroke aphasia

Behavioral language treatment approaches represent the standard of care for persons with aphasia (PWA), but the benefits of these treatments are variable. Moreover, due to the logistic and financial limitations on the amount of behavioral therapy available to patients, it is often infeasible for PWA to receive behavioral interventions with the level of frequency, intensity, or duration that would provide significant and lasting benefit, underscoring the need for novel, effective treatment approaches. Noninvasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have emerged as promising neurally-based tools to enhance language abilities for PWA following stroke. This chapter first provides an overview of the methods and physiologic basis motivating the use of NIBS to enhance aphasia recovery followed by a selective review of the growing evidence of its potential as a novel therapeutic tool. Subsequent sections discuss some of the principles that may prove most useful in guiding and optimizing the effects of NIBS on aphasia recovery, focusing on how the functional state of the brain at the time of stimulation interacts with the behavioral aftereffects of neuromodulation. We conclude with a discussion of current challenges and future directions for NIBS in aphasia treatment.

The Effectiveness of Transcranial Magnetic Stimulation (TMS) Paradigms as Treatment Options for Recovery of Language Deficits in Chronic Poststroke Aphasia

Background

In an effort to boost aphasia recovery, modern rehabilitation, in addition to speech and language therapy (SALT), is increasingly incorporating noninvasive methods of brain stimulation. The present study is aimed at investigating the effectiveness of two paradigms of neuronavigated repetitive transcranial magnetic stimulation (rTMS): (i) 1 Hz rTMS and (ii) continuous theta burst stimulation (cTBS) each as a standalone treatment for chronic aphasia poststroke.

Methods

A single subject experimental design (SSED) trial was carried out in which six people with aphasia (PWA) were recruited, following a single left hemispheric stroke more than six months prior to the study. Three individuals were treated with 1 Hz rTMS, and the remaining three were treated with cTBS. In all cases, TMS was applied over the right pars triangularis (pTr). Language assessment, with standardized and functional measures, and cognitive evaluations were carried out at four time points: twice prior to treatment (baseline), one day immediately posttreatment, and at follow-up two months after treatment was terminated. Quality of life (QoL) was also assessed at baseline and two months posttreatment. In addition, one of the participants with severe global aphasia was followed up again one and two years posttherapy.

Results

For all participants, both rTMS paradigms (1 Hz rTMS and cTBS) generated trends towards improvement in several language skills (i.e., verbal receptive language, expressive language, and naming and reading) one day after treatment and/or two months after therapy. Rated QoL remained stable in three individuals, but for the other three, the communication scores of the QoL were reduced, while two of them also showed a decline in the psychological scores. The participant that was treated with cTBS and followed for up to two years showed that the significant improvement she had initially exhibited in comprehension and reading skills two months after TMS (1^st follow-up) was sustained for at least up to two years.

Conclusion

From the current findings, it is suggested that inhibitory TMS over the right pTr has the potential to drive neuroplastic changes as a standalone treatment that facilitates language recovery in poststroke aphasia.

New Treatment Strategy Using Repetitive Transcranial Magnetic Stimulation for Post-Stroke Aphasia

Repetitive transcranial magnetic stimulation (rTMS) for post-stroke aphasia (PSA) has been suggested to promote improvement of language function when used in combination with rehabilitation. However, many challenges remain. In some reports examined by category of language function, only naming has good evidence of improvement, and the improvement effect on other language modalities is low. Therefore, it is necessary to establish methods that contribute to the improvement of language functions other than naming. Therapeutic methods for PSA based on the mechanism of rTMS are mainly inhibitory stimulation methods for language homologous areas. However, the mechanisms of these methods are controversial when inferred from the process of recovery of language function. Low-frequency rTMS applied to the right hemisphere has been shown to be effective in the chronic phase of PSA, but recent studies of the recovery process of language function indicate that this method is unclear. Therefore, it has been suggested that evaluating brain activity using neuroimaging contributes to confirming the effect of rTMS on PSA and the elucidation of the mechanism of functional improvement. In addition, neuroimaging-based stimulation methods (imaging-based rTMS) may lead to further improvements in language function. Few studies have examined neuroimaging and imaging-based rTMS in PSA, and further research is required. In addition, the stimulation site and stimulation parameters of rTMS are likely to depend on the time from onset to intervention. However, there are no reports of studies in patients between 90 and 180 days after onset. Therefore, research during this period is required. New stimulation methods, such as multiple target methods and the latest neuroimaging methods, may contribute to the establishment of new knowledge and new treatment methods in this field.

A pilot study verifying the effectiveness of high-frequency repetitive transcranial magnetic stimulation in combination with intensive speech-language-hearing therapy in patients with chronic aphasia

BACKGROUND

A lot of research on the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in patients with aphasia in the chronic stage deals with low-frequency stimulation, and reports on high-frequency stimulation (HF-rTMS) are scarce.

OBJECTIVE

The purpose of this study was to evaluate retrospectively the effectiveness of high-frequency rTMS in combination with intensive speech-language-hearing therapy (ST) following the identification of the stimulation site using functional magnetic resonance imaging (fMRI) before, after the procedure and at 3 months in patients with aphasia in the chronic stage.

METHODS

20 patients with aphasia in the chronic stage who met the eligibility criteria for rTMS therapy and who underwent HF-rTMS for the first time were included in the present study. All patients received fMRI before hospitalization, and the stimulation site was decided accordingly.

RESULTS

There was a significant improvement in all patients, rTMS to the left hemisphere, fluent and non-fluent groups by the evaluation of pre- and post- treatment by hospitalization. All groups had a significant improvement in total Standard Language Test of Aphasia score at 3 months when compared with the time of hospitalization.

CONCLUSIONS

The current study indicates that HF-rTMS in combination with intensive ST is an effective therapeutic approach for patients with aphasia in the chronic stage.

A systematic review of repetitive transcranial magnetic stimulation in aphasia rehabilitation: Leads for future studies

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive tool that induces neuromodulation in the brain. Several studies have shown that rTMS improves language recovery in patients with post-stroke aphasia.

OBJECTIVE

This systematic review summarizes the role of rTMS in aphasia rehabilitation.

METHODS

We searched MEDLINE via PubMed and Scopus on 30October, 2020, for English articles (1996-2020). Eligible studies involved post-stroke aphasia rehabilitation with rTMS. In some of these studies, rTMS was also combined with speech therapy.

RESULTS

In total, seven meta-analyses and 59studies (23randomized clinical trials) were included in this systematic review. The methods used in these studies were heterogeneous. Only six studies did not find that rTMS had a significant effect on language performance.

CONCLUSIONS

The evidence from the peer-reviewed literature suggests that rTMS is an effective tool in post-stroke aphasia rehabilitation. However, the precise mechanisms that underlie the effects of rTMS and the reorganization of language networks in patients who have had a stroke remain unclear. We discuss these crucial challenges in the context of future studies.

Increased Recruitment of Domain-General Neural Networks in Language Processing Following Intensive Language-Action Therapy: fMRI Evidence From People With Chronic Aphasia

Purpose This study aimed to provide novel insights into the neural correlates of language improvement following intensive language-action therapy (ILAT; also known as constraint-induced aphasia therapy). Method Sixteen people with chronic aphasia underwent clinical aphasia assessment (Aachen Aphasia Test [AAT]), as well as functional magnetic resonance imaging (fMRI), both administered before (T1) and after ILAT (T2). The fMRI task included passive reading of single written words, with hashmark strings as visual baseline. Results Behavioral results indicated significant improvements of AAT scores across therapy, and fMRI results showed T2-T1 blood oxygenation-level-dependent (BOLD) signal change in the left precuneus to be modulated by the degree of AAT score increase. Subsequent region-of-interest analysis of this precuneus cluster confirmed a positive correlation of T2-T1 BOLD signal change and improvement on the clinical aphasia test. Similarly, the entire default mode network revealed a positive correlation between T2-T1 BOLD signal change and clinical language improvement. Conclusion These results are consistent with a more efficient recruitment of domain-general neural networks in language processing, including those involved in attentional control, following aphasia therapy with ILAT. Supplemental Material https://doi.org/10.23641/asha.12765755.

The management of subacute and chronic vascular aphasia: an updated review

Background

Post-stroke aphasia (PSA) is an impairment of the generation or comprehension of language due to acute cerebrovascular lesions. Subacute phase span the 7th day to 24 weeks post-onset while > 6 months is termed chronic phase. Language recovery does not arise immediately in chronic PSA, unlike the acute phase. The majority of the treatment modalities in these two PSA phases are still in the infancy stage, facing dilemmas and considered experimental requiring constant updates. Hence, we aimed to upgrade the existing literature regarding available PSA management options, advances, and drawbacks pertaining to subacute and chronic phases.

Main text

In this review, we analyzed the management options for subacute and chronic vascular aphasia. MEDLINE, through PubMed, ScienceDirect, and Google Scholar were explored for English studies by utilizing the terms “stroke aphasia” Plus “vascular aphasia”; 160,753 articles were retrieved. The latest studies, published from 2016 to July 2020, were selected. Article headings and abstracts were analyzed for relevance and filtered; eventually, 92 articles were included in this review. Various management options were extracted as follows: noninvasive brain stimulation (NIBS), technology-based therapies, speech-language therapy (SLT), pharmacotherapy, music-based therapies, and psychosocial interventions.

Conclusion

The PSA therapy evolves towards more intense SLT therapy, yet the optimal dosage of the emerging high-intensity therapies is controversial. As spinal and cerebellar NIBS, Telespeech, and E-mental health mark PSA's future, distinct pharmacological options remain a dilemma. Across the continuum of care, PSA–depression comorbidity and inadequate PSA post-discharge education to patient’s families are the significant therapeutic challenges. Future therapeutic mechanisms, optimal dose/timing, and tolerability/safety exploration are obliged.

A Review of Biological Interventions in Chronic Aphasia

Aphasia is a common and debilitating condition following stroke. While the gold standard for aphasia treatment is behavioral speech-language therapy, benefits remain modest in chronic stages of recovery. This limitation motivates the pursuit of novel interventions for chronic aphasia. Here, we review biological approaches that have been used (or proposed for use, in the case of regenerative and genetic therapies) to treat chronic aphasia. These techniques aim to ameliorate the deficits of aphasia by directly manipulating brain function, rather than training lost or compensatory functions, although many have been used to augment effects of behavioral therapy. Specifically, we explore the most robust designs of transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and pharmacotherapy that have been applied in chronic (≥6 months) post-stroke aphasia. We also consider less investigated approaches including epidural cortical stimulation and photobiomodulation. All methods are currently in nascent phases and restricted to experimental studies and clinical trials. Although the evidence base remains limited, such interventions may ultimately improve language function and quality of life for those living with chronic aphasia. However, it is crucial that application of these methods consider the effects of concomitant speech-language therapy, as biological interventions combined with behaviorally induced experience-dependent plasticity will likely yield the most beneficial and durable outcomes.

Effects of repetitive transcranial magnetic stimulation with different frequencies on post-stroke aphasia: A PRISMA-compliant meta-analysis

BACKGROUNDS

Previous studies indicated inconsistent results for the treatment effect of repetitive transcranial magnetic stimulation (rTMS) on post-stroke aphasics. The study conducted a meta-analysis to evaluate whether the rTMS with different frequencies demonstrated any effect in patients with post-stroke aphasia.

METHODS

Electronic databases (PubMed, Web of Science, Medline, EMBASE, and Google Scholar) were searched for articles published before July 2019. Statistical analyses were made using STATA 12.0 software. Standard mean difference (SMD) with 95% confidence intervals (CI) were calculated for the treatment effect of rTMS on post-stroke aphasia.

RESULTS

Meta-analysis indicated significant treatment effects on naming of rTMS in post-stroke aphasics (SMD 0.76, 95%CI 0.16 to 1.36, I = 76.9%, P < .001). Subgroup analyses showed significant treatment effects on naming of low frequency (LF)-rTMS (SMD 0.40, 95%CI 0.10 to 0.69, I = 0.0%, P = .671). However, the changes in repetition and comprehension following stimulation were not significant.

CONCLUSIONS

In conclusion, we provide preliminary evidence that both LF-rTMS and high-frequency-rTMS might be relatively effective and safe treatment for post-stroke aphasics. However, LF-rTMS mainly plays a short-term role in subacute post-stroke aphasics. Longer-term and large-scale studies are essential to explore the effect of rTMS with different frequencies on post-stroke aphasia.

Neuromodulation in post-stroke aphasia treatment

PURPOSE OF REVIEW

This paper aims to review non-invasive brain stimulation (NIBS) methods to augment speech and language therapy (SLT) for patients with post-stroke aphasia.

RECENT FINDINGS

In the past five years there have been more than 30 published studies assessing the effect of transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) for improving aphasia in people who have had a stroke. Different approaches to NIBS treatment have been used in post-stroke aphasia treatment including different stimulation locations, stimulation intensity, number of treatment sessions, outcome measures, type of aphasia treatment, and time post-stroke.

SUMMARY

This review of NIBS for post-stroke aphasia shows that both tDCS and TMS can be beneficial for improving speech and language outcomes for patients with stroke. Prior to translating NIBS to clinical practice, further studies are needed to determine optimal tDCS and TMS parameters as well as the mechanisms underlying tDCS and TMS treatment outcomes.

EEG Artifact Removal in TMS Studies of Cortical Speech Areas

The combination of transcranial magnetic stimulation (TMS) and electroencephalography (EEG) is commonly applied for studying the effective connectivity of neuronal circuits. The stimulation excites neurons, and the resulting TMS-evoked potentials (TEPs) are recorded with EEG. A serious obstacle in this method is the generation of large muscle artifacts from scalp muscles, especially when frontolateral and temporoparietal, such as speech, areas are stimulated. Here, TMS-EEG data were processed with the signal-space projection and source-informed reconstruction (SSP-SIR) artifact-removal methods to suppress these artifacts. SSP-SIR suppressed muscle artifacts according to the difference in frequency contents of neuronal signals and muscle activity. The effectiveness of SSP-SIR in rejecting muscle artifacts and the degree of excessive attenuation of brain EEG signals were investigated by comparing the processed versions of the recorded TMS-EEG data with simulated data. The calculated individual lead-field matrix describing how the brain signals spread on the cortex were used as simulated data. We conclude that SSP-SIR was effective in suppressing artifacts also when frontolateral and temporoparietal cortical sites were stimulated, but it may have suppressed also the brain signals near the stimulation site. Effective connectivity originating from the speech-related areas may be studied even when speech areas are stimulated at least on the contralateral hemisphere where the signals were not suppressed that much.

Transcranial magnetic stimulation-evoked potentials after the stimulation of the right-hemispheric homologue of Broca's area

The combination of transcranial magnetic stimulation and electroencephalography can be applied to probe effective connectivity. Neurons are excited by magnetic pulses, which produce transcranial magnetic stimulation-evoked potentials that can be monitored with electroencephalography. Effective connectivity refers to causal connections in the brain; it describes how different brain areas communicate with each other. Broca's area is crucial for all phases of speech processing and is located in the frontotemporal region of the cortex. Only a few studies have investigated this region using transcranial magnetic stimulation-electroencephalography because of the large cranial muscles that are located over these areas, resulting in large artifacts covering the transcranial magnetic stimulation-evoked potentials. However, it is shown that this obstacle can be overcome with new artifact-removal tools. We used minimum-norm estimation to locate the sources of the neuronal signals in electroencephalography data after stimulating the right-hemispheric homologue of Broca's area in three right-handed subjects; it was shown that the spreading of brain activity might be different for different individuals and that the brain activity spread fast to the contralateral hemisphere.