Current Approaches to the Treatment of Post-Stroke Aphasia

Change of function and brain activity in patients of right spastic arm paralysis combined with aphasia after contralateral cervical seventh nerve transfer surgery

Left hemisphere injury can cause right spastic arm paralysis and aphasia, and recovery of both motor and language functions shares similar compensatory mechanisms and processes. Contralateral cervical seventh cross transfer (CC7) surgery can provide motor recovery for spastic arm paralysis by triggering interhemispheric plasticity, and self-reports from patients indicate spontaneous improvement in language function but still need to be verified. To explore the improvements in motor and language function after CC7 surgery, we performed this prospective observational cohort study. The Upper Extremity part of Fugl-Meyer scale (UEFM) and Modified Ashworth Scale were used to evaluate motor function, and Aphasia Quotient calculated by Mandarin version of the Western Aphasia Battery (WAB-AQ, larger score indicates better language function) was assessed for language function. In 20 patients included, the average scores of UEFM increased by .40 and 3.70 points from baseline to 1-week and 6-month post-surgery, respectively. The spasticity of the elbow and fingers decreased significantly at 1-week post-surgery, although partially recurred at 6-month follow-up. The average scores of WAB-AQ were increased by 9.14 and 10.69 points at 1-week and 6-month post-surgery (P < .001 for both), respectively. Post-surgical fMRI scans revealed increased activity in the bilateral hemispheres related to language centrals, including the right precentral cortex and right gyrus rectus. These findings suggest that CC7 surgery not only enhances motor function but may also improve the aphasia quotient in patients with right arm paralysis and aphasia due to left hemisphere injuries.

Acupuncture, an effective treatment for post-stroke neurologic dysfunction

Stroke episodes represent a significant subset of cerebrovascular diseases globally, often resulting in diverse neurological impairments such as hemiparesis, spasticity, dysphagia, sensory dysfunction, cognitive impairment, depression, aphasia, and other sequelae. These dysfunctions markedly diminish patients' quality of life and impose substantial burdens on their families and society. Consequently, the restoration of neurological function post-stroke remains a primary objective of clinical treatment. Acupuncture, a traditional Chinese medicine technique, is endorsed by the World Health Organization (WHO) for stroke treatment due to its distinct advantages in managing cerebrovascular diseases, including ischemic stroke. Numerous clinical studies have substantiated the efficacy of acupuncture in ameliorating neurological dysfunctions following stroke. This review systematically examines the improvements in post-stroke neurological dysfunction attributable to acupuncture treatment and elucidates potential mechanisms of action proposed in recent years. Additionally, this article aims to present novel therapeutic concepts and strategies for the clinical management of post-stroke neurological dysfunction.

Case report: Applied behavior analysis in a case of anomic aphasia in post-acute myocardial infarction with cardiac arrest and brain hypoxia: results of tact-training

Purpose

Applied Behavior Analysis (ABA) tact-training was provided to an adult with post-stroke anomic aphasia, with the main purposes to improve naming of pictures, with a possible generalization to another different setting, through telehealth sessions.

Method

The Multiple probe experimental design across behaviors was used. Two sets of stimuli were used (SET 1 and SET 2), including 60 laminated photos, belonging to three different categories for each set. Procedure included the baseline, the intervention phases (face-to-face and telehealth sessions), and the follow-up (1 month after the end of a tact training).

Results

For both, SET 1 and SET 2, the mastery criterion (80% correct stimulus tacts, for three consecutive times, simultaneously for all categories) was achieved. No increased percentage of correct picture tacts was found for untrained items. At follow-up, the patient provided 70 to 100% correct responses. For both SET 1 and SET 2, telehealth did not modify the correct response trends.

Conclusion

The results of our study seem to suggest that specific tact-training procedures might be successfully carried out in adult and elderly people with post-stroke aphasia. It also appears necessary to arrange protocols providing telehealth sessions, with benefits for both families and the health system.

Moving Toward Anti-Ableist Practices in Aphasia Rehabilitation and Research: A Viewpoint

PURPOSE

Ableism is a pervasive set of beliefs that regard nondisabled bodies and minds as ideal and necessary to live a full life. Ableism manifests for people with aphasia as stigma and discrimination based on their language ability. We assert that ableism contributes to decreased quality of life for people with aphasia and should be actively challenged and disrupted by clinicians and researchers in the field.

METHOD

We applied the Health Stigma and Discrimination Framework (HSDF) to outline how stigma and discrimination are perpetuated against people with aphasia on the basis of language ability and their downstream health and social consequences. We presented this framework at the Clinical Aphasiology Conference in 2023 and share themes and challenges that arose from this discussion and from our ongoing learning.

DISCUSSION

Applying the HSDF to aphasia outlined potential sequelae of ableism. We identified preliminary foci of future initiatives aimed at challenging ableist beliefs and practices and means to monitor the effectiveness of such interventions. Furthermore, we draw attention to the seeming tension between anti-ableist practices and traditional language rehabilitation goals. We assert that this tension may be a catalyst for fruitful discourse on how clinicians and researchers can resist ableism while honoring the lived experiences of people with aphasia and their goals for language rehabilitation. These discussions may be facilitated by existing models in disability studies (e.g., the political/relational model).

CONCLUSIONS

Clinicians and researchers are well positioned to challenge ableism and minimize the resultant health and social impacts for people living with aphasia. Anti-ableist practices are not antithetical to aphasia rehabilitation and can be thoughtfully integrated into rehabilitation practices and discourse.

A Review of Poststroke Aphasia Recovery and Treatment Options

Poststroke aphasia, which impacts expressive and receptive communication, can have detrimental effects on the psychosocial well-being and the quality of life of those affected. Aphasia recovery is multidimensional and can be influenced by several baseline, stroke-related, and treatment-related factors, including preexisting cerebrovascular conditions, stroke size and location, and amount of therapy received. Importantly, aphasia recovery can continue for many years after aphasia onset. Behavioral speech and language therapy with a speech-language pathologist is the most common form of aphasia therapy. In this review, the authors also discuss augmentative treatment methodologies, collaborative goal setting frameworks, and recommendations for future research.

Prolonged intermittent theta burst stimulation for post-stroke aphasia: protocol of a randomized, double-blinded, sham-controlled trial

Background

Post-stroke aphasia (PSA) is one of the most devastating symptoms after stroke, yet limited treatment options are available. Prolonged intermittent theta burst stimulation (piTBS) is a promising therapy for PSA. However, its efficacy remains unclear. Therefore, we aim to investigate the efficacy of piTBS over the left supplementary motor area (SMA) in improving language function for PSA patients and further explore the mechanism of language recovery.

Methods

This is a randomized, double-blinded, sham-controlled trial. A total of 30 PSA patients will be randomly allocated to receive either piTBS stimulation or sham stimulation for 15 sessions over a period of 3 weeks. The primary outcome is the Western Aphasia Battery Revised (WAB-R) changes after treatment. The secondary outcomes include The Stroke and Aphasia Quality of Life Scale (SAQOL-39 g), resting-state electroencephalogram (resting-state EEG), Event-related potentials (ERP), brain derived neurotrophic factor (BDNF). These outcome measures are assessed before treatment, after treatment, and at 4-weeks follow up. This study was registered in Chinese Clinical Trial Registry (No. ChiCTR23000203238).

Discussion

This study protocol is promising for improving language in PSA patients. Resting-state EEG, ERP, and blood examination can be used to explore the neural mechanisms of PSA treatment with piTBS.

Clinical trial registration

https://www.chictr.org.cn/index.html, ChiCTR2300074533.

AI and Aphasia in the Digital Age: A Critical Review

Aphasiology has a long and rich tradition of contributing to understanding how culture, language, and social environment contribute to brain development and function. Recent breakthroughs in AI can transform the role of aphasiology in the digital age by leveraging speech data in all languages to model how damage to specific brain regions impacts linguistic universals such as grammar. These tools, including generative AI (ChatGPT) and natural language processing (NLP) models, could also inform practitioners working with clinical populations in the assessment and treatment of aphasia using AI-based interventions such as personalized therapy and adaptive platforms. Although these possibilities have generated enthusiasm in aphasiology, a rigorous interrogation of their limitations is necessary before AI is integrated into practice. We explain the history and first principles of reciprocity between AI and aphasiology, highlighting how lesioning neural networks opened the black box of cognitive neurolinguistic processing. We then argue that when more data from aphasia across languages become digitized and available online, deep learning will reveal hitherto unreported patterns of language processing of theoretical interest for aphasiologists. We also anticipate some problems using AI, including language biases, cultural, ethical, and scientific limitations, a misrepresentation of marginalized languages, and a lack of rigorous validation of tools. However, as these challenges are met with better governance, AI could have an equitable impact.

Comprehensive quality assessment for aphasia rehabilitation after stroke: protocol for a multicentre, mixed-methods study

INTRODUCTION

People with aphasia following stroke experience disproportionally poor outcomes, yet there is no comprehensive approach to measuring the quality of aphasia services. The Meaningful Evaluation of Aphasia SeRvicES (MEASuRES) minimum dataset was developed in partnership with people with lived experience of aphasia, clinicians and researchers to address this gap. It comprises sociodemographic characteristics, quality indicators, treatment descriptors and outcome measurement instruments. We present a protocol to pilot the MEASuRES minimum dataset in clinical practice, describe the factors that hinder or support implementation and determine meaningful thresholds of clinical change for core outcome measurement instruments.

METHODS AND ANALYSIS

This research aims to deliver a comprehensive quality assessment toolkit for poststroke aphasia services in four studies. A multicentre pilot study (study 1) will test the administration of the MEASuRES minimum dataset within five Australian health services. An embedded mixed-methods process evaluation (study 2) will evaluate the performance of the minimum dataset and explore its clinical applicability. A consensus study (study 3) will establish consumer-informed thresholds of meaningful change on core aphasia outcome constructs, which will then be used to establish minimal important change values for corresponding core outcome measurement instruments (study 4).

ETHICS AND DISSEMINATION

Studies 1 and 2 have been registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12623001313628). Ethics approval has been obtained from the Royal Brisbane and Women's Hospital (HREC/2023/MNHB/95293) and The University of Queensland (2022/HE001946 and 2023/HE001175). Study findings will be disseminated through peer-reviewed publications, conference presentations and engagement with relevant stakeholders including healthcare providers, policy-makers, stroke and rehabilitation audit and clinical quality registry custodians, consumer support organisations, and individuals with aphasia and their families.

Identifying profiles of stroke patients benefitting from additional training: a latent class analysis approach

OBJECTIVE

To identify profiles of stroke patient benefitting from additional training, using latent class analysis.

DESIGN

Retrospective observational study.

PATIENTS

Patients with stroke (n = 6,875) admitted to 42 recovery rehabilitation units in Japan between January 2005 and March 2016 who were registered in the Japan Association of Rehabilitation Database.

METHODS

The main outcome measure was the difference in Functional Independence Measure (FIM) scores between admission and discharge (referred to as "gain"). The effect of additional training, categorized as usual care (no additional training), self-exercise, training with hospital staff, or both exercise (combining self-exercise and training with hospital staff), was assessed through multiple regression analyses of latent classes.

RESULTS

Applying inclusion and exclusion criteria, 1185 patients were classified into 7 latent classes based on their admission characteristics (class size n = 82 (7%) to n = 226 (19%)). Patients with class 2 characteristics (right hemiparesis and modified dependence in the motor-FIM and cognitive-FIM) had positive FIM gain with additional training (95% confidence interval (95% CI) 0.49-3.29; p < 0.01). One-way analysis of variance revealed that training with hospital staff (95% CI 0.07-16.94; p < 0.05) and both exercises (95% CI 5.38-15.13; p < 0.01) led to a significantly higher mean FIM gain than after usual care.

CONCLUSION

Additional training in patients with stroke with right hemiparesis and modified dependence in activities of daily living was shown to improve activities of daily living. Training with hospital staff combined with self-exercise is a promising rehabilitation strategy for these patients.

A literature review and meta-analysis of the optimal factors study of repetitive transcranial magnetic stimulation in post-infarction aphasia

BACKGROUND

The existing literature indicates that repetitive transcranial magnetic stimulation (rTMS) can potentially enhance the prognosis of poststroke aphasia (PSA). Nevertheless, these investigations did not identify the most effective parameters or settings for achieving optimal treatment outcomes. This study involved a meta-analysis aimed to identify the optimal variables for rTMS in treating post-infarction aphasia to guide the use of rTMS in rehabilitating PSA.

METHODS

PubMed, Embase, and Cochrane Library databases were searched from inception to May 2023, and articles were reviewed manually using subject words and free words and supplemented with references from the included literature to obtain additional relevant literature. The search terms included "poststroke aphasia" and "repetitive transcranial magnetic stimulation (rTMS)" repetitive transcranial magnetic stimulation. Additionally, a review of the reference lists of previously published systematic reviews identified through the Cochrane Database of Systematic Reviews (search terms: poststroke aphasia, rTMS; restrictions: none) and PubMed (search terms: poststroke aphasia, rTMSs; restrictions: systematic review or meta-analysis) was performed. Information from studies involving different doses of rTMS in PSA was independently screened and extracted by 2 researchers.

RESULTS

This meta-analysis included 387 participants with PSA across 18 randomized controlled trials. The results showed that the total pulse had a trend toward a significant correlation with the treatment effect (P = 0.088), while all other variables did not correlate significantly. When rTMS was not grouped by stimulus parameter and location, our nonlinear results showed that when the total pulses were 40,000 (standardized mean difference (SMD):1.86, 95% credible interval (CrI) 0.50 to 3.33), the pulse/session was 1000 (SMD:1.05, 95% CrI 0.55-1.57), and an RMT of 80% (SMD:1.08, 95% CrI 0.60-1.57) had the best treatment effect. When rTMS was grouped by stimulus parameters and location, our nonlinear results showed that when the total low-frequency (LF)-rTMS-right inferior frontal gyrus (RIFG) pulse was 40,000 (SMD:1.76, 95% CrI:0.36-3.29), the pulse/session was 1000 (SMD:1.06, 95% CrI:0.54-1.59). Optimal results were obtained with an RMT of 80% (SMD:1.14, 95% CrI 0.54 - 1.76).

CONCLUSIONS

The optimal treatment effects of rTMS for PSA may be obtained with a total pulse of 40,000, a pulse/session of 1000, and an RMT of 80%. Further rigorous randomized controlled studies are required to substantiate the validity of these results.

Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia: A Randomized Clinical Trial

Importance

Motor aphasia is common among patients with stroke. Acupuncture is recommended as an alternative therapy for poststroke aphasia, but its efficacy remains uncertain.

Objective

To investigate the effects of acupuncture on language function, neurological function, and quality of life in patients with poststroke motor aphasia.

Design, Setting, and Participants

This multicenter, sham-controlled, randomized clinical trial was conducted in 3 tertiary hospitals in China from October 21, 2019, to November 13, 2021. Adult patients with poststroke motor aphasia were enrolled. Data analysis was performed from February to April 2023.

Interventions

Eligible participants were randomly allocated (1:1) to manual acupuncture (MA) or sham acupuncture (SA) groups. Both groups underwent language training and conventional treatments.

Main Outcomes and Measures

The primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and scores on the Chinese Functional Communication Profile (CFCP) at 6 weeks. Secondary outcomes included WAB subitems, Boston Diagnostic Aphasia Examination, National Institutes of Health Stroke Scale, Stroke-Specific Quality of Life Scale, Stroke and Aphasia Quality of Life Scale-39, and Health Scale of Traditional Chinese Medicine scores at 6 weeks and 6 months after onset. All statistical analyses were performed according to the intention-to-treat principle.

Results

Among 252 randomized patients (198 men [78.6%]; mean [SD] age, 60.7 [7.5] years), 231 were included in the modified intention-to-treat analysis (115 in the MA group and 116 in the SA group). Compared with the SA group, the MA group had significant increases in AQ (difference, 7.99 points; 95% CI, 3.42-12.55 points; P = .001) and CFCP (difference, 23.51 points; 95% CI, 11.10-35.93 points; P < .001) scores at week 6 and showed significant improvements in AQ (difference, 10.34; 95% CI, 5.75-14.93; P < .001) and CFCP (difference, 27.43; 95% CI, 14.75-40.10; P < .001) scores at the end of follow-up.

Conclusions and Relevance

In this randomized clinical trial, patients with poststroke motor aphasia who received 6 weeks of MA compared with those who received SA demonstrated statistically significant improvements in language function, quality of life, and neurological impairment from week 6 of treatment to the end of follow-up at 6 months after onset.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR1900026740.

Word Repetition Paired With Startling Stimuli Decreases Aphasia and Apraxia Severity in Severe-to-Moderate Stroke: A Stratified, Single-Blind, Randomized, Phase 1 Clinical Trial

PURPOSE

This prospective, single-blinded, parallel, stratified, randomized clinical trial via telehealth aimed to investigate the impact of Startle Adjuvant Rehabilitation Therapy (START) on aphasia, apraxia of speech (AOS), and quality of life in individuals with chronic stroke. The study hypothesized that START would have a greater effect on AOS-related measures and more severe individuals.

METHOD

Forty-two participants with poststroke aphasia, AOS, or both were randomly assigned to the START or control group. Both groups received 77-dB GET READY and GO cues during a word repetition task for three 1-hr sessions on consecutive days. The START group additionally received 105-dB white noise GO cues during one third of trials. The Western Aphasia Battery-Revised, Apraxia Battery for Adults, Stroke Impact Scale, and Communication Outcomes After Stroke scale were administered at Day 1, Day 5, and 1-month follow-up.

RESULTS

START improved performance on some subtests of the Western Aphasia Battery (Comprehension, Repetition, Reading) and measures of AOS (Diadochokinetic Rate, Increasing Word Length) in individuals with moderate/severe aphasia, whereas moderate/severe controls saw no changes. Individuals with mild aphasia receiving START had improved Reading, whereas mild controls saw improved Comprehension. The START group had increased mood and perceived communication recovery by Day 5, whereas controls saw no changes in quality of life.

CONCLUSIONS

This study is the first to evaluate the impact of training with startling acoustic stimuli on clinical measures of aphasia and AOS. Our findings suggest START can enhance both nontrained speech production and receptive speech tasks in moderate/severe aphasia, possibly by reducing poststroke cortical inhibition. Our findings should be considered carefully, as our limitations include small effect sizes, within-group variability, and low completion rates for quality-of-life assessments and follow-up visits. Future studies should explore a mechanism of action, conduct larger and longer Phase 2 clinical trials, and evaluate long-term retention.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24093519.

International Classification of Functioning, Disability, and Health-based rehabilitation program promotes activity and participation of post-stroke patients

Background

The International Classification of Functioning, Disability, and Health (ICF) model has been applied in post-stroke rehabilitation, yet limited studies explored its clinical application on enhancing patients' Activity and Participation (ICF-A&P) level.

Purpose

This study gathered evidence of the effects of an ICF-based post-stroke rehabilitation program (ICF-PSRP) in enhancing community reintegration in terms of ICF-A&P of post-stroke patients.

Methods

Fifty-two post-stroke patients completed an 8 to 12 weeks multidisciplinary ICF-PSRP after setting personal treatment goals in an outpatient community rehabilitation center. Intake and pre-discharge assessments were administered for primary outcomes of Body function (ICF-BF; e.g., muscle strength) and ICF-A&P (e.g., mobility), and secondary outcomes of perceived improvements in ability (e.g., goal attainment and quality of life).

Results

There were significantly higher levels in the ICF-BF and ICF-A&P domains, except cognitive function under the ICF-BF. Improvements in the primary outcomes predicted corresponding secondary outcomes. Firstly, expressive and receptive functions (ICP-BF) were mediated by the everyday language (ICF-A&P) which predicted patients' satisfaction with the language-related quality of life. Secondly, upper extremity function (ICP-BF) was mediated by the lower extremity mobility (ICF-A&P) predicting work and productivity-related quality of life. Content analyses showed that combined ICF-BF and ICF-A&P contents throughout the ICF-PSRP contributed to the positive treatment effects.

Conclusion

The ICF-PSRP was effective in promoting body function, and activity and participation levels of post-stroke patients. Positive treatment effects are characterized by goal-setting process, cross-domain content design, and community-setting delivery.Clinical trial registration: https://clinicaltrials.gov/study/NCT05941078?id=NCT05941078&rank=1, identifier NCT05941078.

Effects of Jiawei Yiqihuoxue decotion for the treatment of post stroke depression and anxiety

This study retrospectively assessed the effects of Jiawei Yiqihuoxue decotion (JWYQHXD) for the treatment of post stroke depression and anxiety (PSDA). This retrospective study included 72 patients who had undergone PSDA. All patients received flupentixol and melitracen and were divided into treatment (n = 36) and control (n = 36) groups. In addition, all the patients in the treatment group underwent JWYQHXD treatment. All patients in both groups were treated for 8 weeks. The primary outcomes were depression (assessed by Hamilton Depression Scale scores) and anxiety (evaluated by Hamilton anxiety scale scores). The secondary outcomes were quality of life (assessed using the 36-item short form health survey) and adverse events. We collected and analyzed the outcome data before and after treatment. After treatment, patients in the treatment group did not show greater relief on depression (Hamilton depression scale, P > .05) or anxiety (Hamilton anxiety scale, P > .05) than those in the control group. However, there were significant differences in quality of life 36-item short form health survey (physical function, P = .02; physical role, P = .01; and general health, P = .04) between the 2 groups after treatment. This study found that the JWYQHXD may help improve the quality of life of patients with PSDA. Future prospective studies are warranted to confirm these findings.

Efficacy of Aphasia Group Conversation Treatment via Telepractice on Language and Patient-Reported Outcome Measures

PURPOSE

Conversation treatment for people with aphasia (PwA) can lead to significant changes in language impairment and quality of life. The COVID-19 pandemic has resulted in the greater use of telepractice treatment delivery. However, there is little evidence regarding the efficacy of telepractice conversation groups. This study investigated the effects of telepractice group conversation treatment on standardized measures of language function and socially oriented/patient-reported outcomes compared to in-person and no-treatment control data.

METHOD

This study used a mixed within- and between-groups design (repeated measure/pre-post treatment), with a single-subject delayed treatment design (Shadish & Rindskopf, 2007) to establish baseline, pretreatment, and posttreatment periods for the telepractice group. Telepractice results pre- and posttreatment were compared with historical in-person and no-treatment control data obtained from a larger randomized control trial (RCT) from DeDe et al. (2019). The historical comparison data were a subset of RCT participants from the same location and included six in-person participants and seven no-treatment control group participants.

RESULTS

Results of standardized testing conducted at baseline, pretreatment, and posttreatment intervals revealed significant improvement from pre- to posttreatment on repetition and picture description tasks for the telepractice group, and significant improvement from pre- to posttreatment on the Aphasia Communication Outcome Measure, total number of relevant utterances, and percentage of complete utterances for the in-person conversation group. No significant differences were observed in the no-treatment groups.

CONCLUSIONS

In contrast to the no-treatment condition, both the in-person and telepractice conditions showed the benefits of conversation group treatment. The in-person treatment condition showed improvements in a wider number of outcome measures than the telepractice condition. Overall, the results prompt further research regarding telepractice group conversation treatment for PwA.

Personalized functional imaging-guided rTMS on the superior frontal gyrus for post-stroke aphasia: A randomized sham-controlled trial

BACKGROUND

Aphasia affects approximately one-third of stroke patients and yet its rehabilitation outcomes are often unsatisfactory. More effective strategies are needed to promote recovery.

OBJECTIVE

We aimed to examine the efficacy and safety of the theta-burst stimulation (TBS) on the language area in the superior frontal gyrus (SFG) localized by personalized functional imaging, in facilitating post-stroke aphasia recovery.

METHODS

This randomized sham-controlled trial uses a parallel design (intermittent TBS [iTBS] in ipsilesional hemisphere vs. continuous TBS [cTBS] in contralesional hemisphere vs. sham group). Participants had aphasia symptoms resulting from their first stroke in the left hemisphere at least one month prior. Participants received three-week speech-language therapy coupled with either active or sham stimulation applied to the left or right SFG. The primary outcome was the change in Western Aphasia Battery-Revised (WAB-R) aphasia quotient after the three-week treatment. The secondary outcome was WAB-R aphasia quotient improvement after one week of treatment.

RESULTS

Ninety-seven patients were screened between January 2021 and January 2022, 45 of whom were randomized and 44 received intervention (15 in each active group, 14 in sham). Both iTBS (estimated difference = 14.75, p < 0.001) and cTBS (estimated difference = 13.43, p < 0.001) groups showed significantly greater improvement than sham stimulation after the 3-week intervention and immediately after one week of treatment (p's < 0.001). The adverse events observed were similar across groups. A seizure was recorded three days after the termination of the treatment in the iTBS group.

CONCLUSION

The stimulation showed high efficacy and SFG is a promising stimulation target for post-stroke language recovery.

Turning the Spotlight to Cholinergic Pharmacotherapy of the Human Language System

Even though language is essential in human communication, research on pharmacological therapies for language deficits in highly prevalent neurodegenerative and vascular brain diseases has received little attention. Emerging scientific evidence suggests that disruption of the cholinergic system may play an essential role in language deficits associated with Alzheimer's disease and vascular cognitive impairment, including post-stroke aphasia. Therefore, current models of cognitive processing are beginning to appraise the implications of the brain modulator acetylcholine in human language functions. Future work should be directed further to analyze the interplay between the cholinergic system and language, focusing on identifying brain regions receiving cholinergic innervation susceptible to modulation with pharmacotherapy to improve affected language domains. The evaluation of language deficits in pharmacological cholinergic trials for Alzheimer's disease and vascular cognitive impairment has thus far been limited to coarse-grained methods. More precise, fine-grained language testing is needed to refine patient selection for pharmacotherapy to detect subtle deficits in the initial phases of cognitive decline. Additionally, noninvasive biomarkers can help identify cholinergic depletion. However, despite the investigation of cholinergic treatment for language deficits in Alzheimer's disease and vascular cognitive impairment, data on its effectiveness are insufficient and controversial. In the case of post-stroke aphasia, cholinergic agents are showing promise, particularly when combined with speech-language therapy to promote trained-dependent neural plasticity. Future research should explore the potential benefits of cholinergic pharmacotherapy in language deficits and investigate optimal strategies for combining these agents with other therapeutic approaches.

Clinical study of melodic intonation therapy combined with transcranial direct current stimulation for post-stroke aphasia: a single-blind, randomized controlled trial

Background

Globally, more than 10 million new stroke cases occur annually, of which aphasia accounts for about one-third. Aphasia has become an independent predictor of functional dependence and death for the stroke population. The closed-loop rehabilitation of combining behavioral therapy with central nerve stimulation seems to be the research trend of post-stroke aphasia (PSA) due to its advantages in improving linguistic deficits.

Objective

To verify the clinical efficacy of a closed-loop rehabilitation program combining melodic intonation therapy (MIT) with transcranial direct current stimulation (tDCS) for PSA.

Methods

This was a single-center, assessor-blinded, randomized controlled clinical trial, which screened 179 patients and included 39 PSA subjects, with the registration number ChiCTR2200056393 in China. Demographic and clinical data were documented. The primary outcome was the Western Aphasia Battery (WAB) used to assess language function, and the secondary outcomes included Montreal Cognitive Assessment (MoCA), Fugl-Meyer Assessment (FMA), and Barthel Index (BI) for evaluating cognition, motor, and activities of daily living, respectively. With the computer-generated randomization sequence, subjects were randomly divided into the conventional group (CG), MIT combined with sham stimulation group (SG), and MIT combined with tDCS group (TG). After the three-week intervention, the functional changes in each group were analyzed by the paired sample T-test, and the functional difference between the three groups was analyzed by ANOVA.

Results

There was no statistical difference on the baseline. After the intervention, the WAB's aphasia quotient (WAB-AQ), MoCA, FMA, and BI were statistically different in SG and TG, including all the sub-items in WAB and FMA, while only listening comprehension, FMA, and BI were statistically different in CG. The differences of WAB-AQ, MoCA, and FMA were statistically different among the three groups, but BI was not. The post hoc test results revealed that the changes of WAB-AQ and MoCA in TG were more significant than the others.

Conclusion

MIT combined with tDCS can augment the positive effect on language and cognitive recovery in PSA.

A bibliometrix-based visualization analysis of international studies on conversations of people with aphasia: Present and prospects

In recent years, there has been a rapid increase in the number of people with aphasia due to brain lesions worldwide, which has prompted researchers to carry out in-depth studies on the pathogenesis, inducement and prognosis of aphasia from neurology, clinical medicine, psychology and other disciplines. With the deepening of research and understanding of aphasia, it is generally believed that a single discipline can no longer meet the needs of the academic community. Therefore, multidisciplinary integration has emerged and achieved fruitful results. This paper, based on the biblioshiny package run by R, conducts bibliometric analysis on the international interdisciplinary research status of conversation and aphasia, predicts its future development direction, and provides reference for relevant domestic research from international source journals. The results indicate that led by Australia, the United Kingdom, the United States and other countries, the international conversational aphasia research has formed a complete system, and formed a "descriptive study of patients with language disorders" and "applied study of rehabilitation treatment". In the future, while continuing to focus on these two categories of research, the empathy ability of conversational partners and medical staff may be taken into account, in order to better contribute to improving patients' quality of life.

Acupuncture for post-stroke depression: a systematic review and network meta-analysis

BACKGROUND

Patients with post-stroke depression (PSD) usually experience anxiety, hopelessness, and insomnia, which have a negative impact on their daily activities and post-stroke rehabilitation. Acupuncture (AC), as a minimally invasive technique, has become a popular choice for improving depression symptoms. However, it is still unclear which therapy is associated with the best outcomes for PSD. In this review, we aimed to explore the impact of AC in alleviating symptoms of PSD and to evaluate the difference in effectiveness between AC combined with pharmacotherapies and various non-pharmacotherapies.

METHODS

Six databases and three clinical trials registration platforms were searched from inception to March 2023. Randomized clinical trial comparing needle-based AC with pharmacotherapy, and other non-pharmacotherapy or invalid group were included. Two independent reviewers identified eligible studies, and collected data using a pre-made form. A Bayesian network meta-analysis was conducted to assess and compare different techniques using RStudio 3.6.0 with the package 'GEMTC' V.0.8.1. The primary outcome was the efficacy for PSD assessed by scales measuring depressive symptoms. The secondary outcomes were effectiveness for neurological function and the quality of life. The ranking probabilities for all treatment interventions was performed using the Surface Under the Cumulative Ranking curve (SUCRA). The risk of bias was assessed by using the Revised Cochrane Risk of Bias tool 2.

RESULTS

Sixty-two studies, involving 5308 participants published from 2003 to 2022, were included. The results showed that compared with western medicine (WM) (defined as pharmacotherapy for PSD), AC alone or with repetitive transcranial magnetic stimulation (RTMS), Traditional Chinese medicine (TCM) alone or with WM, were superior for alleviating depression symptoms. Compared to Usual Care, AC alone or plus other therapies could significantly decrease scores on the Hamilton Depression Rating scale. According to result of SUCRA, AC plus RTMS had the highest probability of improving depressive symptoms with a probability of 49.43%.

CONCLUSIONS

The results of this study indicate that AC alone or combined with other therapies appears to be effective in improving depression symptoms of stroke survivors. Moreover, in comparison to WM, AC alone or plus RTMS, TCM, TCM with WM, or WM, were more effective in improving depression symptoms of PSD. Also, AC with RTMS seems to be the most effective with the highest probability.

REGISTRATION

This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database in November 2020 and updated in July 2021. The registration number is CRD42020218752.

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.

Theory-driven treatment modifications: A discussion on meeting the linguistic, cognitive, and psychosocial needs of individual clients with aphasia

There is a growing body of literature demonstrating that language rehabilitation can improve naming impairments for individuals with aphasia. However, there are challenges applying evidence-based research to clinical practice. Well-controlled clinical studies often consist of homogenous samples and exclude individuals who may confound group-level results. Consequently, the findings may not generalize to the diverse clients serviced by speech-language therapists. Within evidence-based guidelines, clinicians can leverage their experiences and theoretical rationale to adapt interventions to meet the needs of individual clients. However, modifications to evidence-based interventions should not alter aspects of treatment that are necessary to produce change within the treatment target. The current discussion paper uses errorless learning, errorful learning, and retrieval practice for naming in aphasia to model how treatment theories can guide clinicians in making theory-informed modifications to interventions. First, we briefly describe the learning mechanisms hypothesized to underlie errorless learning, errorful learning, and retrieval practice. Next, we identify ways clinicians can provide targeted supports to optimize learning for individual clients. The paper ends with a reflection on how well-defined treatment theories can facilitate the generation of practice-based evidence and clinically relevant decision making.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02674490.

Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke

Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

SUPPLEMENTAL MATERIAL

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

Effects of repetitive transcranial magnetic stimulation on post-stroke patients with cognitive impairment: A systematic review and meta-analysis

BACKGROUND

Post-stroke cognitive impairment (PSCI) is one of the common symptoms in stroke survivors, by which their quality of life and rehabilitation progress are severely limited. Repetitive transcranial magnetic stimulation (rTMS) has been proven to regulate cognition in a non-invasive way. However, the inconsistency in its effectiveness on PSCI reported in previous studies cannot be ruled out. A critical and comprehensive systematic review of rTMS on PSCI patients is necessary.

METHODS

Trials published before the end of February 2022 on rTMS and PSCI were systematically retrieved from PubMed, Cochrane Library, EBSCO, Embase and SCOPUS. High-quality literature was selected following the inclusion and exclusion criteria, with their references being screened. Meta-analysis of data was carried out using RevMan 5.4 software.

RESULTS

Ten trials involving 347 participants were included in the current review. Global cognition as measured by MMSE or MoCA (SMD=0.54; 95% CI=0.31, 0.76; P < 0.00001; I² = 38%) and modified Barthel index (MD=9.00; 95% CI=2.93, 15.06; P = 0.004; I² = 0%) were significantly improved by rTMS compared to sham stimulation in PSCI patients. Performance of the digit symbol test, rivermead behavioral memory test and attention in PSCI patients were also significantly improved. Subgroup analyses showed that significant differences were found in both MoCA and MMSE among PSCI patients by rTMS. MoCA was significantly improved by high frequency rTMS, while both MoCA and MMSE were significantly improved targeting on left dorsolateral prefrontal cortex.

CONCLUSION

rTMS provides a non-invasive and effective technique for the treatment of post-stroke patients with cognitive impairment.

Treatment-induced neural reorganization in aphasia is language-domain specific: Evidence from a large-scale fMRI study

Studies investigating the effects of language intervention on the re-organization of language networks in chronic aphasia have resulted in mixed findings, likely related to-among other factors-the language function targeted during treatment. The present study investigated the effects of the type of treatment provided on neural reorganization. Seventy individuals with chronic stroke-induced aphasia, recruited from three research laboratories and meeting criteria for agrammatism, anomia or dysgraphia were assigned to either treatment (N = 51) or control (N = 19) groups. Participants in the treatment group received 12-weeks of language intervention targeting sentence comprehension/production, naming, or spelling. At baseline and post-testing, all participants performed an fMRI story comprehension task, with blocks of auditorily-presented stories alternated with blocks of reversed speech. Participants in the treatment, but not control, group significantly improved in the treated language domain. FMRI region-of-interest (ROI) analyses, conducted within regions that were either active (or homologous to active) regions in a group of 22 healthy participants on the story comprehension task, revealed a significant increase in activation from pre-to post-treatment in right-hemisphere homologues of these regions for participants in the sentence and spelling, but not naming, treatment groups, not predicted by left-hemisphere lesion size. For the sentence (but not the spelling) treatment group, activation changes within right-hemisphere homologues of language regions were positively associated with changes in measures of verb and sentence comprehension. These findings support previous research pointing to recruitment of right hemisphere tissue as a viable route for language recovery and suggest that sentence-level treatment may promote greater neuroplasticity on naturalistic, language comprehension tasks, compared to word-level treatment.

Long-term effects of transcranial direct current stimulation (tDCS) combined with speech language therapy (SLT) on post-stroke aphasia patients: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation tool for improving language performance in patients with aphasia after stroke. However, it remains unclear whether it has long-term effects. After consulting a large number of relevant studies, it was found that there are no definitive conclusions about the long-term effects of tDCS on post-stroke aphasia patients.

OBJECTIVE

To determine whether tDCS has long-term effects on post-stroke aphasia patients (PAPs) and which type of tDCS has the most beneficial treatment effects on language performance (especially naming ability).

METHODS

A network meta-analysis was conducted by searching for randomized controlled trials (RCTs) published until April 2023 in the following databases: Web of Science, Embase, Medline (from OVID and PubMed), PsycInfo and PsycARTICLES (from OVID). We only included RCTs published in English. PAPs treated by tDCS combined with speech-language therapy were selected. Sham tDCS was the control group. Naming ability or other language performance must be assessed at follow-up states. Two reviewers independently used checklists to assess the primary outcome (the long-term effects on naming ability) and the secondary outcome (other language performance, such as communication). Cochrane Collaboration guidelines were used to assess the risk of bias.

RESULTS

Seven studies with 249 patients were included for data synthesis. For primary outcomes (naming nous), there was no obvious evidence to show a difference between interventions (C-tDCS vs. S-tDCS SMD = 0.06, 95% CI = -1.01, 1.12; A-tDCS vs. S-tDCS SMD = 0.00, 95% CI = -0.66, 0.65; D-tDCS vs. S-tDCS SMD = 0.77, 95% CI = -0.71, 2.24; A-tDCS vs. C-tDCS SMD = -0.06, 95% CI = -1.31,1.19; D-tDCS vs. C-tDCS SMD = 0.71, 95% CI = -1.11,2.53; D-tDCS vs. A-tDCS SMD = 0.77, 95% CI = -0.84, 2.39). In addition, no evidence showed differences in communication ability (C-tDCS vs. S-tDCS SMD = 0.08 95% CI = -1.77, 1.92; A-tDCS vs. S-tDCS SMD = 1.23 95% CI = -1.89, 4.34; D-tDCS vs. S-tDCS SMD = 0.70; 95% CI = -1.93, 3.34; A-tDCS vs. C-tDCS SMD = 1.15 95% CI = -2.48, 4.77; D-tDCS vs. C-tDCS SMD = 0.62 95% CI = -2.59, 3.84; D-tDCS vs. A-tDCS SMD = -0.52 95% CI = -4.60, 3.56).

CONCLUSION

It seems that tDCS has no long-term effects on post-stroke aphasia patients in naming nouns and communication in terms of the results of our network meta-analysis. However, the results should be interpreted with caution. In the future, more RCTs with long follow-up times should be included in the research to conduct subgroup or meta-regression analyses to obtain a sufficient effect size.

Agrammatic output in non-fluent, including Broca's, aphasia as a rational behavior

Background

Speech of individuals with non-fluent, including Broca's, aphasia is often characterized as "agrammatic" because their output mostly consists of nouns and, to a lesser extent, verbs and lacks function words, like articles and prepositions, and correct morphological endings. Among the earliest accounts of agrammatic output in the early 1900s was the "economy of effort" idea whereby agrammatic output is construed as a way of coping with increases in the cost of language production. This idea resurfaced in the 1980s, but in general, the field of language research has largely focused on accounts of agrammatism that postulated core deficits in syntactic knowledge.

Aims

We here revisit the economy of effort hypothesis in light of increasing emphasis in cognitive science on rational and efficient behavior.

Main contribution

The critical idea is as follows: there is a cost per unit of linguistic output, and this cost is greater for patients with non-fluent aphasia. For a rational agent, this increase leads to shorter messages. Critically, the informative parts of the message should be preserved and the redundant ones (like the function words and inflectional markers) should be omitted. Although economy of effort is unlikely to provide a unifying account of agrammatic output in all patients-the relevant population is too heterogeneous and the empirical landscape too complex for any single-factor explanation-we argue that the idea of agrammatic output as a rational behavior was dismissed prematurely and appears to provide a plausible explanation for a large subset of the reported cases of expressive aphasia.

Conclusions

The rational account of expressive agrammatism should be evaluated more carefully and systematically. On the basic research side, pursuing this hypothesis may reveal how the human mind and brain optimize communicative efficiency in the presence of production difficulties. And on the applied side, this construal of expressive agrammatism emphasizes the strengths of some patients to flexibly adapt utterances in order to communicate in spite of grammatical difficulties; and focusing on these strengths may be more effective than trying to "fix" their grammar.

Still Searching for Understanding: The Importance of Diverse Research Designs, Methods, and Perspectives

BACKGROUND

Evidence-based medicine and evidence hierarchies have been widely adopted and have strongly influenced decision making across many fields, including clinical aphasiology. However, questions remain about the creation, usefulness, and validity of current evidence hierarchies.

AIMS

This article builds on ideas about scientific approaches and evidence originally shared by Elman (1995, 1998, 2006). This article reviews the history of evidence hierarchies and argues that improving the diversity of research designs, methods, and perspectives will improve understanding of the numerous and complex variables associated with aphasia intervention. Researchers and clinicians are encouraged to synthesize diverse types of scientific evidence. It is hoped that this article will stimulate thought and foster discussion in order to encourage high-caliber research of all types.

MAIN CONTRIBUTION

Concepts from a wide variety of fields including philosophy of science, research design and methodology, and precision medicine are brought together in an attempt to focus research on the scientific understanding of aphasia treatment effects.

CONCLUSION

It is hoped that by incorporating diverse research designs, methods, and perspectives, clinical aphasiologists will become better able to provide effective, personalized treatments, ensuring that each person with aphasia is able to improve their communication ability and quality of life.

Brain age predicts long-term recovery in post-stroke aphasia

The association between age and language recovery in stroke remains unclear. Here, we used neuroimaging data to estimate brain age, a measure of structural integrity, and examined the extent to which brain age at stroke onset is associated with (i) cross-sectional language performance, and (ii) longitudinal recovery of language function, beyond chronological age alone. A total of 49 participants (age: 65.2 ± 12.2 years, 25 female) underwent routine clinical neuroimaging (T1) and a bedside evaluation of language performance (Bedside Evaluation Screening Test-2) at onset of left hemisphere stroke. Brain age was estimated from enantiomorphically reconstructed brain scans using a machine learning algorithm trained on a large sample of healthy adults. A subsample of 30 participants returned for follow-up language assessments at least 2 years after stroke onset. To account for variability in age at stroke, we calculated proportional brain age difference, i.e. the proportional difference between brain age and chronological age. Multiple regression models were constructed to test the effects of proportional brain age difference on language outcomes. Lesion volume and chronological age were included as covariates in all models. Accelerated brain age compared with age was associated with worse overall aphasia severity (F(1, 48) = 5.65, P = 0.022), naming (F(1, 48) = 5.13, P = 0.028), and speech repetition (F(1, 48) = 8.49, P = 0.006) at stroke onset. Follow-up assessments were carried out ≥2 years after onset; decelerated brain age relative to age was significantly associated with reduced overall aphasia severity (F(1, 26) = 5.45, P = 0.028) and marginally failed to reach statistical significance for auditory comprehension (F(1, 26) = 2.87, P = 0.103). Proportional brain age difference was not found to be associated with changes in naming (F(1, 26) = 0.23, P = 0.880) and speech repetition (F(1, 26) = 0.00, P = 0.978). Chronological age was only associated with naming performance at stroke onset (F(1, 48) = 4.18, P = 0.047). These results indicate that brain age as estimated based on routine clinical brain scans may be a strong biomarker for language function and recovery after stroke.

Designing and Implementing a Community Aphasia Group: An Illustrative Case Study of the Aphasia Group of Middle Tennessee

PURPOSE

Community aphasia groups serve an important purpose in enhancing the quality of life and psychosocial well-being of individuals with chronic aphasia. Here, we describe the Aphasia Group of Middle Tennessee, a community aphasia group with a 17-year (and continuing) history, housed within Vanderbilt University Medical Center in Nashville, Tennessee.

METHOD

We describe in detail the history, philosophy, design, curriculum, and facilitation model of this group. We also present both quantitative and qualitative outcomes from group members and their loved ones.

RESULTS

Group members and their loved ones alike indicated highly positive assessments of the format and value of the Aphasia Group of Middle Tennessee.

CONCLUSION

By characterizing in detail the successful Aphasia Group of Middle Tennessee, we hope this can serve as a model for clinicians interested in starting their own community aphasia groups, in addition to reaching individuals living with chronic aphasia and their loved ones through the accessible and aphasia-friendly materials provided with this clinical focus article.

Transcranial Direct Current Stimulation Paired With Verb Network Strengthening Treatment Improves Verb Naming in Primary Progressive Aphasia: A Case Series

PURPOSE

There are few evidence-based treatments for language deficits in primary progressive aphasia (PPA). PPA treatments are often adopted from the poststroke aphasia literature. The poststroke aphasia literature has shown promising results using Verb Network Strengthening Treatment (VNeST), a behavioral therapy that focuses on improving naming by producing verbs and their arguments in phrases and sentences. Emerging research in poststroke aphasia and PPA has shown promising results pairing behavioral language therapy with transcranial direct current stimulation (tDCS).

METHOD

This study used a double-blind, within-subjects, sham-controlled crossover design to study the effect of anodal tDCS applied to left inferior frontal gyrus (IFG) plus VNeST versus VNeST plus sham stimulation in two individuals with nonfluent variant PPA and one individual with logopenic variant PPA. Participants received two phases of treatment, each with 15 1-hr sessions of VNeST. One phase paired VNeST with tDCS stimulation, and one with sham. For each phase, language testing was conducted at baseline, and at 1 week and 8 weeks posttreatment conclusion. For each participant, treatment efficacy was evaluated for each treatment phase by comparing the mean change in accuracy between baseline and the follow-up time points for naming trained verbs (primary outcome measure), untrained verbs, and nouns on the Object and Action Naming Battery. Mean change from baseline was also directly compared between tDCS and sham phases at each time point.

RESULTS

Results revealed a different pattern of outcomes for each of the participants. A tDCS advantage was not found for trained verbs for any participant. Two participants with nonfluent variant PPA had a tDCS advantage for generalization to naming of untrained verbs, which was apparent at 1 week and 8 weeks posttreatment. One participant with nonfluent variant also showed evidence of generalization to sentence production in the tDCS phase.

CONCLUSION

VNeST plus anodal tDCS stimulation of left IFG shows promising results for improving naming in PPA.

Potential Benefits of Music Therapy on Stroke Rehabilitation

Stroke is associated with a high rate of disability and mortality, and survivors are usually accompanied with dysphagia, aphasia, motor dysfunction, cognitive impairment, depression, and other complications. In the past decades, many studies have been conducted to reveal the pathogenesis and pathological mechanisms of stroke. Furthermore, treatment methods have been developed that contribute to the elevated survival rate of stroke patients. Early rehabilitation poststroke is starting to be recognized as important and has been receiving increasing attention in order to further improve the quality of life of the patients. As an emerging method of poststroke rehabilitation, music therapy can help attenuate dysphagia and aphasia, improve cognition and motor function, alleviate negative moods, and accelerate neurological recovery in stroke patients. This review helps summarize the recent progress that has been made using music therapy in stroke rehabilitation and is aimed at providing clinical evidence for the treatment of stroke patients.

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

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

Resting-State Neural-Activity Alterations in Subacute Aphasia after Stroke

Linguistic deficits are frequent symptoms among stroke survivors. The neural mechanism of post-stroke aphasia (PSA) was incompletely understood. Recently, resting-state functional magnetic resonance imaging (rs-fMRI) was widely used among several neuropsychological disorders. However, previous rs-fMRI studies of PSA were limited to very small sample size and the absence of reproducibility with different neuroimaging indexes. The present study performed comparisons with static and dynamic amplitude of low-frequency fluctuations (ALFF) and functional connectivity (FC) based on modest sample size (40 PSA and 37 healthy controls). Compared with controls, PSA showed significantly increased static ALFF predominantly in the bilateral supplementary motor area (SMA) and right hippocampus-parahippocampus (R HIP-ParaHip) and decreased static ALFF in right cerebellum. The increased dynamic ALFF in SMA and decreased dynamic ALFF in right cerebellum were also found in PSA. The static and dynamic ALFF in right cerebellum was positively correlated with spontaneous speech. The FC between the SMA and R HIP-ParaHip was significantly stronger in patients than controls and positively correlated with ALFF in bilateral SMA. In addition, the FC between the R HIP-ParaHip and the right temporal was also enhanced in patients and negatively correlated with repetition, naming, and comprehension score. These findings revealed consistently abnormal intrinsic neural activity in SMA and cerebellum, which may underlie linguistic deficits in PSA.

Revealing the Neuroimaging Mechanism of Acupuncture for Poststroke Aphasia: A Systematic Review

Background

Aphasia is a common symptom in stroke patients, presenting with the impairment of spontaneous speech, repetition, naming, auditory comprehension, reading, and writing function. Multiple rehabilitation methods have been suggested for the recovery of poststroke aphasia, including medication treatment, behavioral therapy, and stimulation approach. Acupuncture has been proven to have a beneficial effect on improving speech functions in repetition, oral speech, reading, comprehension, and writing ability. Neuroimaging technology provides a visualized way to explore cerebral neural activity, which helps reveal the therapeutic effect of acupuncture therapy. In this systematic review, we aim to reveal and summarize the neuroimaging mechanism of acupuncture therapy on poststroke aphasia to provide the foundation for further study.

Methods

Seven electronic databases were searched including PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, the Wanfang databases, and the Chinese Scientific Journal Database. After screening the studies according to the inclusion and exclusion criteria, we summarized the neuroimaging mechanism of acupuncture on poststroke aphasia, as well as the utilization of acupuncture therapy and the methodological characteristics.

Result

After searching, 885 articles were retrieved. After removing the literature studies, animal studies, and case reports, 16 studies were included in the final analysis. For the acupuncture type, 10 studies used manual acupuncture and 5 studies used electroacupuncture, while body acupuncture (10 studies), scalp acupuncture (7 studies), and tongue acupuncture (8 studies) were applied for poststroke aphasia patients. Based on blood oxygen level-dependent (BOLD) and diffusion tensor imaging (DTI) technologies, 4 neuroimaging analysis methods were used including amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), seed-based analysis, and independent component analysis (ICA). Two studies reported the instant acupuncture effect, and 14 studies reported the constant acupuncture's effect on poststroke aphasia patients. 5 studies analyzed the correlation between the neuroimaging outcomes and the clinical language scales.

Conclusion

In this systematic review, we found that the mechanism of acupuncture's effect might be associated with the activation and functional connectivity of language-related brain areas, such as brain areas around Broca's area and Wernicke's area in the left inferior temporal gyrus, supramarginal gyrus, middle frontal gyrus, and inferior frontal gyrus. However, these studies were still in the preliminary stage. Multicenter randomized controlled trials (RCT) with large sample sizes were needed to verify current evidence, as well as to explore deeply the neuroimaging mechanisms of acupuncture's effects.

History of aphasia: A broad overview

This chapter gives a broad overview of the description and theorizing of a wide range of language disorders resulting from brain damage, commonly classified under the umbrella term "aphasia." It covers works written in Antiquity up to the 20th century. Moreover, it looks at disturbances in various language modalities such as speech, language comprehension, reading, writing, and sign language. In addition, also forms of the more recently discovered primary progressive aphasia are discussed. Finally, important developments in the history of assessment and rehabilitation of language disorders are described. To properly characterize disorders of language, these developments are discussed from the perspectives of neurology, psychology, and linguistics.

Disrupted Functional Connectivity Within and Between Resting-State Networks in the Subacute Stage of Post-stroke Aphasia

Background: Post-stroke aphasia (PSA) results from brain network disorders caused by focal stroke lesions. However, it still remains largely unclear whether the impairment is present in intra- and internetwork functional connectivity (FC) within each resting-state network (RSN) and between RSNs in the subacute stage of PSA.

Objectives: This study aimed to investigate the resting-state FC within and between RSNs in patients with PSA and observe the relationships between FC alterations and Western Aphasia Battery (WAB) measures.

Methods: A total of 20 individuals with subacute PSA and 20 healthy controls (HCs) were recruited for functional MRI (fMRI) scanning, and only patients with PSA underwent WAB assessment. Independent component analysis was carried out to identify RSNs. Two-sample t-tests were used to calculate intra- and internetwork FC differences between patients with PSA and HCs. The results were corrected for multiple comparisons using the false discovery rate (FDR correction, p < 0.05). Partial correlation analysis was performed to observe the relationship between FC and WAB scores with age, gender, mean framewise displacement, and lesion volume as covariates (p < 0.05).

Results: Compared to HCs, patients with PSA showed a significant increase in intranetwork FC in the salience network (SN). For internetwork FC analysis, patients showed a significantly increased coupling between left frontoparietal network (lFPN) and SN and decreased coupling between lFPN and right frontoparietal network (rFPN) as well as between lFPN and posterior default mode network (pDMN) (FDR correction, p < 0.05). Finally, a significant positive correlation was found between the intergroup difference of FC (lFPN-rFPN) and auditory-verbal comprehension (p < 0.05).

Conclusion: Altered FC was revealed within and between multiple RSNs in patients with PSA at the subacute stage. Reduced FC between lFPN and rFPN was the key element participating in language destruction. These findings proved that PSA is a brain network disorder caused by focal lesions; besides, it may improve our understanding of the pathophysiological mechanisms of patients with PSA at the subacute stage.

Clinical and Neural Predictors of Treatment Response to Music Listening Intervention after Stroke

Patients with post-stroke impairments present often significant variation in response to therapeutic interventions. Recent studies have shown that daily music listening can aid post-stroke recovery of language and memory, but reliable predictors of treatment response are unknown. Utilizing data from the music intervention arms of a single-blind randomized controlled trial (RCT) on stroke patients (N = 31), we built regression models to predict the treatment response of a two-month music listening intervention on language skills and verbal memory with baseline demographic, clinical and musical data as well as fMRI data from a music listening task. Clinically, greater improvement in verbal memory and language skills after the music listening intervention were predicted by the severity of the initial deficit and educational level. Neurally, greater baseline fMRI activation during vocal music listening in the left parietal cortical and medial frontal areas predicted greater treatment-induced improvement in language skills and greater baseline engagement of the auditory network during instrumental music listening predicted improvement in both verbal memory and language skills. Our results suggest that clinical, demographic, and neuroimaging data predicts music listening treatment response. This data could be used clinically to target music-based treatments.

Novel Advances to Post-Stroke Aphasia Pharmacology and Rehabilitation

Aphasia is one of the most common clinical features of functional impairment after a stroke. Approximately 21–40% of stroke patients sustain permanent aphasia, which progressively worsens one’s quality of life and rehabilitation outcomes. Post-stroke aphasia treatment strategies include speech language therapies, cognitive neurorehabilitation, telerehabilitation, computer-based management, experimental pharmacotherapy, and physical medicine. This review focuses on current evidence of the effectiveness of impairment-based aphasia therapies and communication-based therapies (as well as the timing and optimal treatment intensities for these interventions). Moreover, we present specific interventions, such as constraint-induced aphasia therapy (CIAT) and melodic intonation therapy (MIT). Accumulated data suggest that using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) is safe and can be used to modulate cortical excitability. Therefore, we review clinical studies that present TMS and tDCS as (possible) promising therapies in speech and language recovery, stimulating neuroplasticity. Several drugs have been used in aphasia pharmacotherapy, but evidence from clinical studies suggest that only nootropic agents, donepezil and memantine, may improve the prognosis of aphasia. This article is an overview on the current state of knowledge related to post-stroke aphasia pharmacology, rehabilitation, and future trends.