Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting

Advanced Brain Age and Chronic Poststroke Aphasia Severity

BACKGROUND AND OBJECTIVES

Chronic poststroke language impairment is typically worse in older individuals or those with large stroke lesions. However, there is unexplained variance that likely depends on intact tissue beyond the lesion. Brain age is an emerging concept, which is partially independent from chronologic age. Advanced brain age is associated with cognitive decline in healthy older adults; therefore, we aimed to investigate the relationship with stroke aphasia. We hypothesized that advanced brain age is a significant factor associated with chronic poststroke language impairments, above and beyond chronologic age, and lesion characteristics.

METHODS

This cohort study retrospectively evaluated participants from the Predicting Outcomes of Language Rehabilitation in Aphasia clinical trial (NCT03416738), recruited through local advertisement in South Carolina (US). Primary inclusion criteria were left hemisphere stroke and chronic aphasia (≥12 months after stroke). Participants completed baseline behavioral testing including the Western Aphasia Battery-Revised (WAB-R), Philadelphia Naming Test (PNT), Pyramids and Palm Trees Test (PPTT), and Wechsler Adult Intelligence Scale Matrices subtest, before completing 6 weeks of language therapy. The PNT was repeated 1 month after therapy. We leveraged modern neuroimaging techniques to estimate brain age and computed a proportional difference between chronologic age and estimated brain age. Multiple linear regression models were used to evaluate the relationship between proportional brain age difference (PBAD) and behavior.

RESULTS

Participants (N = 93, 58 males and 35 females, average age = 61 years) had estimated brain ages ranging from 14 years younger to 23 years older than chronologic age. Advanced brain age predicted performance on semantic tasks (PPTT) and language tasks (WAB-R). For participants with advanced brain aging (n = 47), treatment gains (improvement on the PNT) were independently predicted by PBAD (T = -2.0474, p = 0.0468, 9% of variance explained).

DISCUSSION

Through the application of modern neuroimaging techniques, advanced brain aging was associated with aphasia severity and performance on semantic tasks. Notably, therapy outcome scores were also associated with PBAD, albeit only among participants with advanced brain aging. These findings corroborate the importance of brain age as a determinant of poststroke recovery and underscore the importance of personalized health factors in determining recovery trajectories, which should be considered during the planning or implementation of therapeutic interventions.

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.

The nature of inpatient rehabilitation for people with aphasia from culturally and linguistically diverse backgrounds: a scoping review

BACKGROUND

Due to language and cultural barriers, people with aphasia from culturally and linguistically diverse (CALD) backgrounds are at risk of disadvantage in their access to comprehensive care. They are at higher risk of poorer inpatient outcomes in addition to challenges in receiving appropriate aphasia assessment and intervention.

OBJECTIVES

This study aims to examine the extent and nature of what is known about the inpatient phase of aphasia rehabilitation for CALD stroke survivors and identify potential research gaps in the literature for investigation.

METHODS

A scoping review with systematic search was conducted in September 2020 following the PRISMA Scoping Review checklist. Five electronic databases were searched using a combination of terms pertaining to "aphasia," "inpatient care" and "CALD." Key variables were extracted from studies that met the inclusion criteria for analysis.

RESULTS

Eighteen studies were yielded. Data regarding the inpatient phase of care indicate that CALD people with aphasia do not always receive comprehensive assessment or intervention in all their languages that may impact their discharge destination and access to community services. Speech-language pathologists (SLPs) report numerous barriers to service provision for this population. No studies investigated the degree and nature of differences in outcomes between CALD and non-CALD stroke survivors with aphasia.

CONCLUSIONS

CALD stroke survivors with aphasia inconsistently access SLP services in hospital. Assessment is unlikely to be conducted in patient primary languages and therapy is usually provided in the language of SLPs. Further research is required to determine whether this impacts functional outcomes and health services.

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.

Reorganization and Plasticity of the Language Network in Patients with Cerebral Gliomas

Language is organized in large-scale networks in the human brain that show a strong potential for flexible interactions and adaptation. Neuroplasticity is the central mechanism that allows such dynamic modulation to changing conditions across the life span and is particularly important for network reorganization after brain lesions. Most studies on language reorganization focused on language recovery after stroke. Yet, a strong degree of adaptive neuroplasticity can also be observed in patients with brain tumors in language-eloquent brain areas. This review discusses key mechanisms for neural reorganization in patients with brain tumors. Our main aim is to elucidate the underlying mechanisms for intra- and interhemispheric plasticity in the language network in these patients. The following reorganization patterns are discussed: 1) Persisting function within the tumor; 2) Reorganization in perilesional regions; 3) Reorganization in a distributed network of the affected hemisphere; 4) Reorganization to the contralesional hemisphere. In this context, we shed light on language-related reorganization patterns in frontal and temporo-parietal areas and discuss their functional relevance. We also address tumor-related changes in structural and functional connectivity between eloquent brain regions. Thereby, we aim to expand the general understanding of the plastic potential of the neural language network and facilitate clinical decision-making processes for effective, function-preserving tumor treatment.

Repetitive transcranial magnetic stimulation (rTMS) combined with multi-modality aphasia therapy for chronic post-stroke non-fluent aphasia: A pilot randomized sham-controlled trial

Repetitive transcranial magnetic stimulation (rTMS) shows promise in improving speech production in post-stroke aphasia. Limited evidence suggests pairing rTMS with speech therapy may result in greater improvements. Twenty stroke survivors (>6 months post-stroke) were randomized to receive either sham rTMS plus multi-modality aphasia therapy (M-MAT) or rTMS plus M-MAT. For the first time, we demonstrate that rTMS combined with M-MAT is feasible, with zero adverse events and minimal attrition. Both groups improved significantly over time on all speech and language outcomes. However, improvements did not differ between rTMS or sham. We found that rTMS and sham groups differed in lesion location, which may explain speech and language outcomes as well as unique patterns of BOLD signal change within each group. We offer practical considerations for future studies and conclude that while combination therapy of rTMS plus M-MAT in chronic post-stroke aphasia is safe and feasible, personalized intervention may be necessary.

Examining Dose Frameworks to Improve Aphasia Rehabilitation Research

The effect of treatment dose on recovery of post-stroke aphasia is not well understood. Inconsistent conceptualization, measurement, and reporting of the multiple dimensions of dose hinders efforts to evaluate dose-response relations in aphasia rehabilitation research. We review the state of dose conceptualization in aphasia rehabilitation and compare the applicability of 3 existing dose frameworks to aphasia rehabilitation research-the Frequency, Intensity, Time, and Type (FITT) principle, the Cumulative Intervention Intensity (CII) framework, and the Multidimensional Dose Articulation Framework (MDAF). The MDAF specifies dose in greater detail than the CII framework and the FITT principle. On this basis, we selected the MDAF to be applied to 3 diverse examples of aphasia rehabilitation research. We next critically examined applicability of the MDAF to aphasia rehabilitation research and identified the next steps needed to systematically conceptualize, measure, and report the multiple dimensions of dose, which together can progress understanding of the effect of treatment dose on outcomes for people with aphasia after stroke. Further consideration is required to enable application of this framework to aphasia interventions that focus on participation, personal, and environmental interventions and to understand how the construct of episode difficulty applies across therapeutic activities used in aphasia interventions.

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

INTRODUCTION

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions

PURPOSE

Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP.

METHODS

Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis.

RESULTS AND CONCLUSIONS

17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).

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.

A systematic review of maintenance following intensive therapy programs in chronic post-stroke aphasia: importance of individual response analysis

PURPOSE

Recent evidence supports the benefit of intensive aphasia intervention programs for people with chronic aphasia, yet it is unclear if all participants can expect positive outcomes and for how long therapeutic gains last.

METHODS

We systematically searched for studies investigating intensive interventions in chronic aphasia. To explore individual response rates and maintenance of therapeutic gains we carried out meta-synthesis by calculating and analysing the Standard Error of Measurement and Minimal Detectable Change metrics of six common outcome measures.

RESULTS

Forty-four studies comprising 24 experimental (13 group, 11 single-subject) and 20 non-experimental studies met our inclusion criteria (n = 670). Whereas most group studies reported statistically significant post-therapy improvement and maintenance, analysis of individual participant data (IPD, n = 393) from these studies revealed that only about a third of participants were classified as "immediate responders," of which more than a third had lost their initial immediate gains at follow-up. This pattern did not change when IPD from single-subject studies (n = 49) was added to the analysis. Thus, only 22% of all IPD receiving an intensive intervention improved significantly and maintained their therapy gains.

CONCLUSIONS

Intensive aphasia therapy is effective when measured at the group-level, but many individuals do not respond significantly to the intervention, and even fewer individuals preserve their initial gains. Group study results do not allow prediction of an individual's response to the intervention. Future research should elucidate which factors mediate positive treatment response and maintenance for an individual.Implications for rehabilitationOnly a small proportion (about one fifth in this review) of intensive aphasia treatment program participants respond and maintain their therapy gains, a fact that is obscured by traditional p-value group analysis.A simple clinical decision-making method is presented for evaluating individual therapy gains and their maintenance.For some immediate treatment responders (about one third in this review), gains from intensive therapy programs are unlikely to be maintained in the long-term without additional, ongoing practice.Clinicians should consider the possibility of individual clients losing some of their therapy gains and take proactive steps to support long-term maintenance.

Better long-term speech outcomes in stroke survivors who received early clinical speech and language therapy: What's driving recovery?

Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.

Melodic Intonation Therapy for aphasia: A multi-level meta-analysis of randomized controlled trials and individual participant data

Melodic Intonation Therapy (MIT) is a prominent rehabilitation program for individuals with post-stroke aphasia. Our meta-analysis investigated the efficacy of MIT while considering quality of outcomes, experimental design, influence of spontaneous recovery, MIT protocol variant, and level of generalization. Extensive literature search identified 606 studies in major databases and trial registers; of those, 22 studies-overall 129 participants-met all eligibility criteria. Multi-level mixed- and random-effects models served to separately meta-analyze randomized controlled trial (RCT) and non-RCT data. RCT evidence on validated outcomes revealed a small-to-moderate standardized effect in noncommunicative language expression for MIT-with substantial uncertainty. Unvalidated outcomes attenuated MIT's effect size compared to validated tests. MIT's effect size was 5.7 times larger for non-RCT data compared to RCT data (g̅case report = 2.01 vs. g̅RCT = 0.35 for validated Non-Communicative Language Expression measures). Effect size for non-RCT data decreased with number of months post-stroke, suggesting confound through spontaneous recovery. Deviation from the original MIT protocol did not systematically alter benefit from treatment. Progress on validated tests arose mainly from gains in repetition tasks rather than other domains of verbal expression, such as everyday communication ability. Our results confirm the promising role of MIT in improving trained and untrained performance on unvalidated outcomes, alongside validated repetition tasks, and highlight possible limitations in promoting everyday communication ability.

The efficacy of a directed rhythmic-melodic voice training in the treatment of chronic non-fluent aphasia-Behavioral and imaging results

The main objective of this study was to investigate the efficacy of a directed rhythmic-melodic voice training (SIPARI) compared to language therapy with the focus on improvement in expressive linguistic performance. 20 patients suffering from chronic non-fluent aphasia, allocated by coin tossing to either of the groups, participated in 32 single therapy sessions over a period of 4 months. Before and after therapy, independent testers performed a standardized language test (Aachener Aphasie Test). Behavioral assessments revealed that improvements of patients of the experimental group were clinically significant compared to those of the control group. These improvements concerned the description level articulation and prosody for spontaneous speech and the subtests repetition, naming, and comprehension. Based on these improvements, a significant increase in profile level (effect size (ES) = 2.028, p < 0.001) was assessed, an overall and clinically relevant measure of the severity of aphasia. Additional fMRI examinations yielded activation in the left superior frontal gyrus for the post-minus pre- therapy assessments only for participants of the experimental group. Since this brain region is reported to be particularly involved in executive processing, we assume that the directed procedure of the SIPARI treatment with regard to musical, linguistic, and cognitive function potentially holds the key for successful language rehabilitation. While our imaging results hint at a possible explanation for its efficacy, our behavioral results corroborate the efficacy of this therapy in the treatment of chronic non-fluent aphasia patients. DRKS00026730, 19.10.21, retrospectively registered https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00026730.

Exploring How People with Expressive Aphasia Interact with and Perceive a Social Robot

People with aphasia need high-intensive language training to significantly improve their language skills, however practical barriers arise. Socially assistive robots have been proposed as a possibility to provide additional language training. However, it is yet unknown how people with aphasia perceive interacting with a social robot, and which factors influence this interaction. The aim of this study was to gain insight in how people with mild to moderate chronic expressive aphasia perceived interacting with the social robot NAO, and to explore what needs and requisites emerged. A total of 11 participants took part in a single online semi-structured interaction, which was analysed using observational analysis, thematic analysis, and post-interaction questionnaire. The findings show that participants overall felt positive towards using the social robot NAO. Moreover, they perceived NAO as enjoyable, useful, and to a lesser extent easy to use. This exploratory study provides a tentative direction for the intention of people with mild to moderate chronic expressive aphasia to use social robots. Design implications and directions for future research are proposed.

Medidas de Calidad de Vida en Personas con Afasia. Revisión Sistemática

La afasia después de un daño cerebral y sus diferentes condiciones negativas derivadas, afectan a la calidad de vida (CdV) de la persona. El objetivo de este estudio es describir y analizar la literatura de los años comprendidos entre 2016 y 2020 para identificar y cuantificar aspectos relevantes de la CdV y su evaluación en personas con afasia (PWA). Para lo anterior, se consultaron tres bases de datos (PsycINFO, Medline y Psicodoc). Se incluyeron 38 estudios. Se codificaron y analizaron las características de los estudios y se evaluó la calidad de los trabajos siguiendo las pautas marcadas por la STROBE y la NIH. Los resultados muestran que la prueba de evaluación de CdV más utilizada fue la Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39) (n= 19, 50.00%). En la mayoría de los estudios, independientemente de las pruebas de evaluación, las PWA presentan una baja CdV. Los estudios seleccionados presentan una calidad metodológica media-alta. Como conclusión cabe destacar que, además de limitar aspectos de la comunicación y el lenguaje, la afasia afecta negativamente a la CdV de forma global de la persona que la padece. El desarrollo de pruebas de evaluación de la CdV puede ayudar a los profesionales a planificar una intervención adecuada.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia

BACKGROUND

While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.

METHODS

We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.

RESULTS

We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.

CONCLUSIONS

CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.

TRIAL REGISTRATION NUMBER

ACTRN 2615000618550.

Cardiometabolic multimorbidity and activity limitation: a cross-sectional study of adults using the Canadian Longitudinal Study on Aging data

BACKGROUND

Cardiometabolic multimorbidity (CM) is the diagnosis of 2 or more cardiometabolic conditions. Multimorbidity and individual cardiometabolic conditions have been associated with activity limitation, a common form of disability, but few studies have investigated the association between CM and activity limitation.

OBJECTIVES

To estimate the prevalence of activity limitation among Canadians with CM and to quantify the association between CM and activity limitation.

METHODS

Using data from the Canadian Longitudinal Study on Aging, we conducted a cross-sectional analysis of activity limitation among Canadians aged 45-85 (n = 50,777; weighted n = 13,118,474). CM was defined as the diagnosis of 2 or more of diabetes/prediabetes, myocardial infarction, and stroke, and activity limitation was evaluated using the Older Americans Resources and Services scale. Descriptive statistics and logistic and multinomial logistic regression analyses were conducted to determine the association between CM and activity limitation.

RESULTS

The estimated prevalence of activity limitation among participants living with CM was 27.4% compared with 7.5% with no cardiometabolic conditions. Activity limitation increased in prevalence and severity with the number of cardiometabolic conditions. People with CM had increased odds of activity limitation compared with those without any cardiometabolic conditions (adjusted relative risk ratio = 3.99, 95% confidence interval [3.35-4.75]), and the odds increased with each additional condition. Stroke survivors had greater odds of activity limitation than those without a history of stroke and the same number of cardiometabolic conditions.

CONCLUSION

Activity limitation is common among Canadians living with CM. Odds of activity limitation increase with each additional cardiometabolic condition, especially for stroke survivors.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

PURPOSE

Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach.

METHOD

Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision.

RESULTS

Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery.

CONCLUSIONS

Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Poor Performer: A Distinct Entity in Cochlear Implant Users?

INTRODUCTION

Several factors are known to influence speech perception in cochlear implant (CI) users. To date, the underlying mechanisms have not yet been fully clarified. Although many CI users achieve a high level of speech perception, a small percentage of patients does not or only slightly benefit from the CI (poor performer, PP). In a previous study, PP showed significantly poorer results on nonauditory-based cognitive and linguistic tests than CI users with a very high level of speech understanding (star performer, SP). We now investigate if PP also differs from the CI user with an average performance (average performer, AP) in cognitive and linguistic performance.

METHODS

Seventeen adult postlingually deafened CI users with speech perception scores in quiet of 55 (9.32) % (AP) on the German Freiburg monosyllabic speech test at 65 dB underwent neurocognitive (attention, working memory, short- and long-term memory, verbal fluency, inhibition) and linguistic testing (word retrieval, lexical decision, phonological input lexicon). The results were compared to the performance of 15 PP (speech perception score of 15 [11.80] %) and 19 SP (speech perception score of 80 [4.85] %). For statistical analysis, U-Test and discrimination analysis have been done.

RESULTS

Significant differences between PP and AP were observed on linguistic tests, in Rapid Automatized Naming (RAN: p = 0.0026), lexical decision (LexDec: p = 0.026), phonological input lexicon (LEMO: p = 0.0085), and understanding of incomplete words (TRT: p = 0.0024). AP also had significantly better neurocognitive results than PP in the domains of attention (M3: p = 0.009) and working memory (OSPAN: p = 0.041; RST: p = 0.015) but not in delayed recall (delayed recall: p = 0.22), verbal fluency (verbal fluency: p = 0.084), and inhibition (Flanker: p = 0.35). In contrast, no differences were found hereby between AP and SP. Based on the TRT and the RAN, AP and PP could be separated in 100%.

DISCUSSION

The results indicate that PP constitute a distinct entity of CI users that differs even in nonauditory abilities from CI users with an average speech perception, especially with regard to rapid word retrieval either due to reduced phonological abilities or limited storage. Further studies should investigate if improved word retrieval by increased phonological and semantic training results in better speech perception in these CI users.

Cognitive Training to Enhance Aphasia Therapy (Co-TrEAT): A Feasibility Study

Persons with aphasia (PWA) often have deficits in cognitive domains such as working memory (WM), which are negatively correlated with recovery, and studies have targeted WM deficits in aphasia therapy. To our knowledge, however, no study has examined the efficacy of multi-modal training which includes both WM training and targeted language therapy. This pilot project examined the feasibility and preliminary efficacy of combining WM training and naming therapy to treat post-stroke PWA. Chronic PWA were randomly assigned to either the a) Phonological Components Analysis (PCA) and WM intervention (WMI) condition (i.e., a computerized adaptive dual n-back task), or b) PCA and active control condition (WMC). Participants received face-to-face PCA therapy 3 times/week for 5 weeks, and simultaneously engaged in WM training or the active control condition five times/week, independently at home. Six PWA were enrolled, 3 in each condition. Feasibility metrics were excellent for protocol compliance, retention rate and lack of adverse events. Recruitment was less successful, with insufficient participants for group analyses. Participants in the WMI (but not the WMC) condition demonstrated a clinically significant (i.e., > 5 points) improvement on the Western Aphasia Battery- Aphasia Quotient (WAB-R AQ) and Boston Naming Test after therapy. Given the small sample size, the performance of two individuals, matched on age, education, naming accuracy pre-treatment, WAB-R AQ and WM abilities was compared. Participant WMI-3 demonstrated a notable increase in WM training performance over the course of therapy; WMC-2 was the matched control. After therapy, WMI-3's naming accuracy for the treated words improved from 30 to 90% (compared to 30–50% for WMC-2) with a 7-point WAB-R AQ increase (compared to 3 for WMC-2). Improvements were also found for WMI-3 but not for WMC-2 on ratings of communicative effectiveness, confidence and some conversation parameters in discourse. This feasibility study demonstrated excellent results for most aspects of Co-TrEAT. Recruitment rate, hampered by limited resources, must be addressed in future trials; remotely delivered aphasia therapy may be a possible solution. Although no firm conclusions can be drawn, the case studies suggest that WM training has the potential to improve language and communication outcomes when combined with aphasia therapy.

Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis

BACKGROUND AND PURPOSE

Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia.

METHODS

Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori-defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI).

RESULTS

Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58-26.16] Western Aphasia Battery-Aphasia Quotient; 5.23 [1.51-8.95] Aachen Aphasia Test-Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3-5+ days/week), and comprehension (4-5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases.

CONCLUSIONS

Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018110947.

Effective interventions within the scope of occupational therapy practice to address participation for adults with aphasia: A systematic review

Introduction

Occupational therapists work with clients with impaired communication to re-engage in valued occupations. This systematic review seeks to answer the question: What are effective interventions within the scope of occupational therapy practice to address participation for adults with aphasia?

Method

A systematic review of the literature was completed using PubMed, PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Database of Systematic Reviews, and OT Seeker databases. Intervention studies within the scope of occupational therapy practice with a participation outcome, and published in peer reviewed journals from 2000 to 2019, were included. The quality of each study was assessed using the Mixed Methods Appraisal Tool.

Findings

Thirteen articles fit the inclusion criteria. Categories of interventions that emerged from the data include community-based groups, individually tailored programs, adaptation/presentation of materials, interprofessional interventions, and psychoeducation.

Conclusion

There is evidence to support the use of interventions within the scope of occupational therapy practice to increase participation for people with aphasia. Specifically, the use of community-based groups and adaptation of materials are effective to facilitate participation. Most of the studies were pre-post one group design; however, they demonstrated positive results for participation outcomes. More research is needed on people with aphasia that focuses on participation in meaningful occupations.

Genetics in aphasia recovery

Considerable research efforts have been exerted toward understanding the mechanisms underlying recovery in aphasia. However, predictive models of spontaneous and treatment-induced recovery remain imprecise. Some of the hitherto unexplained variability in recovery may be accounted for with genetic data. A few studies have examined the effects of the BDNF val66met polymorphism on aphasia recovery, yielding mixed results. Advances in the study of stroke genetics and genetics of stroke recovery, including identification of several susceptibility genes through candidate-gene or genome-wide association studies, may have implications for the recovery of language function. The current chapter discusses both the direct and indirect evidence for a genetic basis of aphasia recovery, the implications of recent findings within the field, and potential future directions to advance understanding of the genetics-recovery associations.

Behavioral interventions for poststroke aphasia

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

What is Functional Communication? A Theoretical Framework for Real-World Communication Applied to Aphasia Rehabilitation

Aphasia is an impairment of language caused by acquired brain damage such as stroke or traumatic brain injury, that affects a person’s ability to communicate effectively. The aim of rehabilitation in aphasia is to improve everyday communication, improving an individual’s ability to function in their day-to-day life. For that reason, a thorough understanding of naturalistic communication and its underlying mechanisms is imperative. The field of aphasiology currently lacks an agreed, comprehensive, theoretically founded definition of communication. Instead, multiple disparate interpretations of functional communication are used. We argue that this makes it nearly impossible to validly and reliably assess a person’s communicative performance, to target this behaviour through therapy, and to measure improvements post-therapy. In this article we propose a structured, theoretical approach to defining the concept of functional communication. We argue for a view of communication as “situated language use”, borrowed from empirical psycholinguistic studies with non-brain damaged adults. This framework defines language use as: (1) interactive, (2) multimodal, and (3) contextual. Existing research on each component of the framework from non-brain damaged adults and people with aphasia is reviewed. The consequences of adopting this approach to assessment and therapy for aphasia rehabilitation are discussed. The aim of this article is to encourage a more systematic, comprehensive approach to the study and treatment of situated language use in aphasia.

Plasticity of the language system in children and adults

The language system is perhaps the most unique feature of the human brain's cognitive architecture. It has long been a quest of cognitive neuroscience to understand the neural components that contribute to the hierarchical pattern processing and advanced rule learning required for language. The most important goal of this research is to understand how language becomes impaired when these neural components malfunction or are lost to stroke, and ultimately how we might recover language abilities under these circumstances. Additionally, understanding how the language system develops and how it can reorganize in the face of brain injury or dysfunction could help us to understand brain plasticity in cognitive networks more broadly. In this chapter we will discuss the earliest features of language organization in infants, and how deviations in typical development can-but in some cases, do not-lead to disordered language. We will then survey findings from adult stroke and aphasia research on the potential for recovering language processing in both the remaining left hemisphere tissue and in the non-dominant right hemisphere. Altogether, we hope to present a clear picture of what is known about the capacity for plastic change in the neurobiology of the human language system.

Transcranial Direct-Current Stimulation and Behavioral Training, a Promising Tool for a Tailor-Made Post-stroke Aphasia Rehabilitation: A Review

Aphasia is an acquired language disorder resulting from damage to portions of the brain which are responsible for language comprehension and formulation. This disorder can involve different levels of language processing with impairments in both oral and written comprehension and production. Over the last years, different rehabilitation and therapeutic interventions have been developed, especially non-invasive brain stimulation (NIBS) techniques. One of the most used NIBS techniques in aphasia rehabilitation is the Transcranial Direct-Current Stimulation (tDCS). It has been proven to be effective in promoting a successful recovery both in the short and the long term after a brain injury. The main strength of tDCS is its feasibility associated with relatively minor side effects, if safely and properly administered. TDCS requires two electrodes, an anode and a cathode, which are generally placed on the scalp. The electrode montage can be either unipolar or bipolar. The main aim of this review is to give an overview of the state of the art of tDCS for the treatment of aphasia. The studies described included patients with different types of language impairments, especially with non-fluent aphasia and in several cases anomia. The effects of tDCS are variable and depend on several factors, such as electrode size and montage, duration of the stimulation, current density and characteristics of the brain tissue underneath the electrodes. Generally, tDCS has led to promising results in rehabilitating patients with acquired aphasia, especially if combined with different language and communication therapies. The selection of the appropriate approach depends on the patients treated and their impaired language function. When used in combination with treatments such as Speech and Language Therapy, Constraint Induced Aphasia Therapy or Intensive Action Treatment, tDCS has generally promoted a better recovery of the impaired functions. In addition to these rehabilitation protocols, Action Observation Therapy, such as IMITAF, appeared to contribute to the reduction of post-stroke anomia. The potential of combining such techniques with tDCS would would therefore be a possibility for further improvement, also providing the clinician with a new action and intervention tool. The association of a tDCS protocol with a dedicated rehabilitation training would favor a generalized long-term improvement of the different components of language.

Right-hemispheric language reorganization in patients with brain arteriovenous malformations: A functional magnetic resonance imaging study

Brain arteriovenous malformation (AVM), a presumed congenital lesion, may involve traditional language areas but usually does not lead to language dysfunction unless it ruptures. The objective of this research was to study right-hemispheric language reorganization patterns in patients with brain AVMs using functional magnetic resonance imaging (fMRI). We prospectively enrolled 30 AVM patients with lesions involving language areas and 32 age- and sex-matched healthy controls. Each subject underwent fMRI during three language tasks: visual synonym judgment, oral word reading, and auditory sentence comprehension. The activation differences between the AVM and control groups were investigated by voxelwise analysis. Lateralization indices (LIs) for the frontal lobe, temporal lobe, and cerebellum were compared between the two groups, respectively. Results suggested that the language functions of AVM patients and controls were all normal. Voxelwise analysis showed no significantly different activations between the two groups in visual synonym judgment and oral word reading tasks. In auditory sentence comprehension task, AVM patients had significantly more activations in the right precentral gyrus (BA 6) and right cerebellar lobule VI (AAL 9042). According to the LI results, the frontal lobe in oral word reading task and the temporal lobe in auditory sentence comprehension task were significantly more right-lateralized in the AVM group. These findings suggest that for patients with AVMs involving language cortex, different language reorganization patterns may develop for different language functions. The recruitment of brain areas in the right cerebral and cerebellar hemispheres may play a compensatory role in the reorganized language network of AVM patients.

Treatment dose in post-stroke aphasia: A systematic scoping review

Little is known about how the amount of treatment a person with aphasia receives impacts aphasia recovery following stroke, yet this information is vital to ensure effective treatments are delivered efficiently. Furthermore, there is no standard dose terminology in the stroke rehabilitation or aphasia literature. This scoping review aims to systematically map the evidence regarding dose in treatments for post-stroke aphasia and to explore how treatment dose is conceptualized, measured and reported in the literature. A comprehensive search was undertaken in June 2019. One hundred and twelve intervention studies were reviewed. Treatment dose (amount of treatment) has been conceptualized as both a measure of time and a count of discrete therapeutic elements. Doses ranged from one to 100 hours, while some studies reported session doses of up to 420 therapeutic inputs per session. Studies employ a wide variety of treatment schedules (i.e., session dose, session frequency, and intervention duration) and the interaction of dose parameters may impact the dose-response relationship. High dose interventions delivered over short periods may improve treatment efficiency while maintaining efficacy. Person- and treatment-level factors that mediate tolerance of high dose interventions require further investigation. Systematic exploration of dose-response relationships in post-stroke aphasia treatment is required.

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

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

COVID-19 and Aphasia

PURPOSE OF REVIEW

Aphasia is an acquired neurological language disorder after brain damages. Persons with aphasia (PWA) are more susceptible to behavioral and emotional implications due to inherent communication and/or cognitive difficulties. Currently, little is known regarding the impact of COVID-19 on PWA.

RECENT FINDINGS

There are now growing reports with evidence of neurological and dysexecutive syndromes subsequent to interference of brain functions in acute patients with COVID-19, leading to variable aphasia-like symptoms. COVID-19 affected chronic PWA more in terms of disrupted communication and daily routines, worsened psychosocial well-being, and difficulties getting aphasia services that adequately addressed their needs. Acute versus chronic PWA were disproportionately affected by COVID-19. Recognizing, examining, and managing COVID-19-related neurological and behavioral problems in PWA is not straightforward. As we passed the 1-year mark and approaching the 2-year mark of the onset of COVID-19, more research is necessary to prioritize strategies for improving current evidence-based care and rehabilitation of aphasia.

Long-Term Stability of Short-Term Intensive Language-Action Therapy in Chronic Aphasia: A 1-2 year Follow-Up Study

Background. Intensive aphasia therapy can improve language functions in chronic aphasia over a short therapy interval of 2-4 weeks. For one intensive method, intensive language-action therapy, beneficial effects are well documented by a range of randomized controlled trials. However, it is unclear to date whether therapy-related improvements are maintained over years. Objective. The current study aimed at investigating long-term stability of ILAT treatment effects over circa 1-2 years (8-30 months). Methods. 38 patients with chronic aphasia participated in ILAT and were re-assessed at a follow-up assessment 8-30 months after treatment, which had been delivered 6-12.5 hours per week for 2-4 weeks. Results. A standardized clinical aphasia battery, the Aachen Aphasia Test, revealed significant improvements with ILAT that were maintained for up to 2.5 years. Improvements were relatively better preserved in comparatively young patients (<60 years). Measures of communicative efficacy confirmed improvements during intensive therapy but showed inconsistent long-term stability effects. Conclusions. The present data indicate that gains resulting from intensive speech-language therapy with ILAT are maintained up to 2.5 years after the end of treatment. We discuss this novel finding in light of a possible move from sparse to intensive therapy regimes in clinical practice.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Auditory Comprehension Deficits in Post-stroke Aphasia: Neurologic and Demographic Correlates of Outcome and Recovery

Introduction: One of the most challenging symptoms of aphasia is an impairment in auditory comprehension. The inability to understand others has a direct impact on a person's quality of life and ability to benefit from treatment. Despite its importance, limited research has examined the recovery pattern of auditory comprehension and instead has focused on aphasia recovery more generally. Thus, little is known about the time frame for auditory comprehension recovery following stroke, and whether specific neurologic and demographic variables contribute to recovery and outcome.

Methods: This study included 168 left hemisphere chronic stroke patients stroke patients with auditory comprehension impairments ranging from mild to severe. Univariate and multivariate lesion-symptom mapping (LSM) was used to identify brain regions associated with auditory comprehension outcomes on three different tasks: Single-word comprehension, yes/no sentence comprehension, and comprehension of sequential commands. Demographic variables (age, gender, and education) were also examined for their role in these outcomes. In a subset of patients who completed language testing at two or more time points, we also analyzed the trajectory of recovery in auditory comprehension using survival curve-based time compression.

Results: LSM analyses revealed that poor single-word auditory comprehension was associated with lesions involving the left mid- to posterior middle temporal gyrus, and portions of the angular and inferior-middle occipital gyri. Poor yes/no sentence comprehension was associated almost exclusively with the left mid-posterior middle temporal gyrus. Poor comprehension of sequential commands was associated with lesions in the left posterior middle temporal gyrus. There was a small region of convergence between the three comprehension tasks, in the very posterior portion of the left middle temporal gyrus. The recovery analysis revealed that auditory comprehension scores continued to improve beyond the first year post-stroke. Higher education was associated with better outcome on all auditory comprehension tasks. Age and gender were not associated with outcome or recovery slopes.

Conclusions: The current findings suggest a critical role for the posterior left middle temporal gyrus in the recovery of auditory comprehension following stroke, and that spontaneous recovery of auditory comprehension can continue well beyond the first year post-stroke.

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.

Factors predicting long-term recovery from post-stroke aphasia

BACKGROUND

It remains widely accepted that spontaneous recovery from aphasia is largely limited to the first related factors. This has direct implications for acute and chronic interventions for aphasia. few months following stroke. A few recent studies challenge this view, revealing that some individuals' language abilities improve even during the chronic stage.

AIMS

To identify prognostic indicators of long-term aphasia recovery.

METHODS & PROCEDURES

Eighteen people with aphasia initially evaluated in the chronic stage were retested at least one year later. The Western Aphasia Battery-Revised (WAB-R) Aphasia Quotient (AQ) was used to quantify changes in language impairment. Prognostic factors included those related to the patient (demographic, psychosocial), stroke (lesion volume and location), and treatment (medical, rehabilitative).

OUTCOMES & RESULTS

Twelve participants improved and 6 remained stable or declined. Linear regression analysis revealed that lesion volume predicted long-term language gains, with smaller lesions yielding greater improvements. Individuals who did not improve were more likely to have lesions encompassing critical frontal and temporoparietal cortical regions and interconnecting white matter pathways. Exploratory regression analysis of psychosocial and treatment-related factors revealed a positive relationship between improvement and satisfaction with life participation, and a negative relationship between improvement and perceived impairment severity. Critically, psychosocial and treatment-related factors significantly improved model fit over lesion volume, suggesting that these factors add predictive value to determining long-term aphasia prognosis.

CONCLUSIONS

Long-term aphasia recovery is multidetermined by a combination of stroke-, psychosocial-, and treatment-related factors. This has direct implications for acute and chronic interventions for aphasia.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

People with aphasia at least 6 months post stroke.

INTERVENTION

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NCT03245060.

Individualized response to semantic versus phonological aphasia therapies in stroke

Attempts to personalize aphasia treatment to the extent where it is possible to reliably predict individual response to a particular treatment have yielded inconclusive results. The current study aimed to (i) compare the effects of phonologically versus semantically focussed naming treatment and (ii) examine biographical and neuropsychological baseline factors predictive of response to each treatment. One hundred and four individuals with chronic post-stroke aphasia underwent 3 weeks of phonologically focussed treatment and 3 weeks of semantically focussed treatment in an unblinded cross-over design. A linear mixed-effects model was used to compare the effects of treatment type on proportional change in correct naming across groups. Correlational analysis and stepwise regression models were used to examine biographical and neuropsychological predictors of response to phonological and semantic treatment across all participants. Last, chi-square tests were used to explore the association between treatment response and phonological and semantic deficit profiles. Semantically focussed treatment was found to be more effective at the group-level, independently of treatment order (P = 0.041). Overall, milder speech and language impairment predicted good response to semantic treatment (r range: 0.256-0.373) across neuropsychological tasks. The Western Aphasia Battery-Revised Spontaneous Speech score emerged as the strongest predictor of semantic treatment response (R 2 = 0.188). Severity of stroke symptoms emerged as the strongest predictor of phonological treatment response (R 2 = 0.103). Participants who showed a good response to semantic treatment were more likely to present with fluent speech compared to poor responders (P = 0.005), whereas participants who showed a good response to phonological treatment were more likely to present with apraxia of speech (P = 0.020). These results suggest that semantic treatment may be more beneficial to the improvement of naming performance in aphasia than phonological treatment, at the group-level. In terms of personalized predictors, participants with relatively mild impairments and fluent speech responded better to semantic treatment, while phonological treatment benefitted participants with more severe impairments and apraxia of speech.

Efficacy of a strategy-based intervention on text-level reading comprehension in persons with aphasia: a study protocol for a repeated measures study

INTRODUCTION

At least 68% of persons with aphasia (PWA) experience reading difficulties. Even though strategy-based interventions are a promising treatment approach for text level reading comprehension deficits in PWA, empirical evidence for their efficacy remains rare. The primary objective of this study is the analysis of the efficacy of a strategy-based intervention on text-level reading comprehension and on reading activities in PWA.

METHODS AND ANALYSIS

In a repeated measures trial, 24 PWA will first participate in a waiting period and then in a strategy-based intervention (14 face-to-face-sessions, 60 min each). We will apply two combinations of strategies to treat either the microstructure or the macrostructure, respectively. Participants will be randomly allocated to two parallel groups that will receive these combinations in interchanged sequences. Assessments will be implemented before and after each period as well as 3 and 6 months after the intervention. The primary outcome measure is text-level reading comprehension measured with a German version of the Test de Compréhension de Textes (TCT-D) and represented by the score TCT-D Total . A non-blinded and a blinded rater will evaluate the primary outcome measure. Secondary outcome measures will address specific reading functions, reading activities and cognitive functions. The sample size was determined with an a priori power analysis. For statistical analysis, we will use contrast analyses within repeated measures analysis of variance models. We expect significant improvements in primary and secondary outcome measures during the intervention as compared with changes during the waiting period.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of Deutscher Bundesverband für akademische Sprachtherapie und Logopädie (20-10074-KA-MunmErw+Ko). Results and relevant data will be disseminated in peer-reviewed journals, at conferences and on the Open Science Framework.

TRIAL REGISTRATION NUMBER

DRKS00021411 (see Supplementary Table 1).

Improvement in Language Function in Patients with Aphasia using Computer-Assisted Executive Function Training: A Controlled Clinical Trial

OBJECTIVE

Non-verbal cognitive training has gained popularity for the management of aphasia. The correlation between language function and cognitive control has been explored previously. Cognitive status affects language to a certain degree. In this study, we aimed to determine whether non-verbal computer-assisted executive control training (CAET) to improve cognitive status affects language performance in patients with aphasia (PWA).

DESIGN

A total of 73 participants were included in the study, and 5 subjects dropped out. A total of 68 individuals were randomly divided into two groups and underwent treatment. The experimental group was treated with traditional speech and language therapy (SLT) combined with CAET. The control group underwent SLT only.

RESULTS

Differences between pre- and post-treatment language outcomes expect oral naming (group × time, P = 0.236) were significantly greater in the experimental group compared with the control group: Spontaneous speech (group × time, P = 0.026), Auditory Comprehension (group × time, P < 0.001), Speech repetition (group × time, P = 0.001), AQ (group × time, P < 0.001). A similar effect was observed for cognitive function such as TMT-A (group × time, P = 0.006), TMT-B (group × time, P = 0.005) and VFT-V (group × time, P = 0.018).

CONCLUSION

Our study demonstrates that CAET combined with SLT can yield favorable language outcomes for PWA, especially improvements in auditory comprehension and AQ. CAET combined with SLT generates benefits in both cognitive function and language performance. Therefore, CAET may be applied as an adjuvant aphasia therapy in conjunction with traditional SLT. This article is protected by copyright. All rights reserved.