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

Anomia prehabilitation in temporal lobe epilepsy surgery: A pilot study

OBJECTIVE

An emerging approach in surgery is to propose prehabilitation programs to strengthen the patient's functional abilities before surgical interventions, thus helping them cope better with its consequences. In drug-resistant language-dominant temporal lobe epilepsy (LdTLE), surgical treatment carries a risk of increasing cognitive deficits, notably word-finding difficulties (anomia) and verbal memory difficulties that negatively impact personal, social, and occupational activities. In this study, we invited 15 LdTLE patients to enroll in a speech and language prehabilitation program adapted to the specifics of their difficulties, organized daily during the preoperative period.

METHODS

Naming performance (for trained and untrained words) was studied twice before prehabilitation, during prehabilitation, and 1 week and 6 months after surgery. Results were analyzed using a generalized linear mixed effects model.

RESULTS

We found a significant effect of prehabilitation on trained items before surgery. Postoperatively, trained items showed a slight and nonsignificant performance increase compared to baseline, whereas untrained items showed a significant decline in the same comparison.

SIGNIFICANCE

We conclude that trained words were better protected from postsurgical decline than untrained words. Our research can contribute to patient support during surgical decision-making; ultimately, prehabilitation might be considered as part of individualized care. These encouraging results lay the groundwork for more detailed or powerful examinations of the protective effect of prehabilitation on language skills.

Assessing Functional Communication in Persons With Aphasia: A Scoping Review of Formal and Informal Measures

BACKGROUND

The communicative effectiveness of persons with aphasia (PWA) has been assessed through a range of functional communication measures. However, variability in interpretations of what is covered by the term "functional communication" may have resulted in challenges to the implementation of appropriate and consistent patient-centred evaluations, with different measures focusing on subsets of the components of functional communication.

AIMS

This paper aims to examine the current literature on informal and formal evaluation of functional communication in PWA and to identify gaps in currently available assessment tools.

METHODS

This scoping review included studies published between 1965 and 2024 that assessed functional communication in PWA, excluding studies focused on non-aphasic populations or impairment-based assessments without real-world application. Systematic searches were conducted in PubMed, Embase, CINAHL, Scopus, and PsycINFO using predefined search terms. Of the 541 studies identified, 67 met the inclusion criteria after title/abstract and full-text screening. Measures were categorized as formal (standardized) or informal (non-standardized) and evaluated based on contextuality, multimodality, and interactiveness. Informal assessments also emphasized life participation, quality of life, augmentative alternative communication (AAC) strategies, conversational discourse, the informativeness and complexity of language use, and real-world communicative transactions.

MAIN CONTRIBUTION

In the 67 studies included in the literature review, 32 functional communication assessments were identified across the categories of informal and formal evaluation. Informal assessments (28) included patient-reported, clinician-reported, observer-reported, and performance-based outcome measures. Formal functional communication assessments (4) included systematically normed instruments provided to PWA under controlled conditions, yielding a diagnosis or level of specified functional communication capability. Of the reviewed informal and formal measures, a limited quantity met all criteria for a comprehensive assessment of functional communication in aphasia, namely, being contextual, multimodal, and interactive.

CONCLUSIONS

Existing assessments reveal gaps in the comprehensive evaluation of functional communication. The findings emphasize the need for standardized, multimodal, and context-sensitive tools that better reflect the dynamic, real-world communicative needs of PWA.

WHAT THIS PAPER ADDS

What is already known on the subject Functional communication is recognized as a cornerstone for assessing real-world abilities in persons with aphasia (PWA). However, current assessments vary in their design and implementation, reflecting the diverse approaches taken across clinical and research settings. What this paper adds to existing knowledge This study emphasizes the importance of integrating contextuality, multimodality, and interactiveness into functional communication assessments. It highlights the valuable contributions of informal tools, which offer adaptability and focus on life participation, and identifies opportunities to enhance formal tools to better address real-world communication needs. What are the potential or clinical implications of this work? Developing standardized, holistic tools for functional communication assessment will provide clinicians and researchers with more effective resources to evaluate and support PWA. These advancements will promote consistency in practice, enable meaningful comparisons across studies, and ultimately improve life participation and communication outcomes for PWA.

Implicit structural priming as a treatment component for aphasia: Specifying essential learning conditions

This study applies implicit structural priming as a novel treatment for sentence production in persons with aphasia (PWA), investigating the learning mechanism(s) that drive robust and enduring recovery. Sixteen PWA and 16 controls completed baseline, three training sessions, and 1-day and 1-week post-testing. Each participant received both alternating and single structure prime training conditions to test error-based versus repeated activation-based learning. Both groups showed significantly improved production and maintenance of trained and untrained target sentences in both training conditions. While controls showed greater gains following alternating prime structure training, single prime structure training resulted in greater improvements for PWA. These results suggest that structural priming is an effective training for aphasia. Additionally, to the extent that the different priming conditions reflected different mechanisms underlying the learning and access of impaired structure, increased base-level activation of target syntactic structure supports learning of grammatical encoding in aphasia more effectively than processing prime sentences with competing syntactic structures.

Structural Priming for Sentence Production in Aphasia: What Does Oral Repetition Do?

PURPOSE

Structural priming-speakers' unconscious tendency to reuse previously encountered sentence structures (primes) in future production-facilitates access and learning of grammatical representations in persons with aphasia (PWAs). However, it remains unclear which components of structural priming tasks are essential to consistent and lasting effects, a discovery critical for cost-effective clinical translation of research. We examined the effects of orally repeating versus listening to primes on immediate and lasting sentence production in PWAs and controls.

METHOD

In a collaborative priming task, participants took turns with the experimenter, describing transitive and dative event pictures. One group of PWAs and controls listened to the experimenter's descriptions (primes) before they described their own picture, whereas the other group orally repeated their interlocutor's prime sentences before the target picture descriptions. In Experiment 1, the target picture description was elicited immediately after the prime (0-lag, immediate priming). In Experiment 2, two filler trials (2-lag) intervened between prime and target, examining longer term priming.

RESULTS

At both immediate and longer term priming, significant priming effects were observed in both groups, as indicated by increased productions of passives following passive versus active primes and increased productions of double-object dative sentences following double-object than prepositional object dative prime sentences. However, orally repeating prime sentences did not reliably and consistently enhance the magnitude of priming effects across lags and groups. Additionally, PWAs' repetition abilities did not result in higher degrees of priming effects.

CONCLUSION

These findings suggest that opportunities for processing syntactic representations that shared between prior (prime) and current (target) utterances is a rather essential ingredient for positive structural priming in PWAs, while repeating prime sentences is an optional ingredient that can be removed or modified.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28291949.

Self-Improved Language Production in Nonfluent Aphasia Through Automated Recursive Self-Feedback

BACKGROUND

Persons with nonfluent aphasia (PWNA) use feedback from external agents (e.g., speech-language pathologists) and self-feedback to improve their language production. The extent to which PWNA can improve their language production using their self-feedback alone is underexplored. In a proof-of-concept study, we developed an automated recursive self-feedback procedure to demonstrate the extent to which two PWNA who used self-feedback alone improved their production of sentences from trained and untrained scripts. In the current study, we use the Rehabilitation Response Specification System as a framework to replicate our initial findings.

METHOD

We tested the effects of two treatments: script production with recursive self-feedback and script production with external feedback in four persons with chronic nonfluent aphasia. We compared the effects of treatment by measuring percent script produced, speaking rate, and speech initiation latency of trained and untrained scripts. The participants received the treatments remotely through mini tablets using two versions of a mobile app we developed. All the participants received each treatment intensively for 14 sessions across 2-3 weeks. We estimated clinical improvements of production of sentences from trained and untrained scripts through nonoverlap of all pairs analysis of performance pretreatment and posttreatment.

RESULTS

Both treatments improved PWNA's language production. Recursive self-feedback improved speaking rate and speech initiation latency, which generalized to untrained scripts in all participants. External feedback treatment did not generalize to improvement in speaking rate in two participants.

CONCLUSIONS

Our findings confirm our initial evidence that PWNA can self-improve their sentence production from scripts through recursive self-feedback. This novel procedure enables PWNA to autonomously enhance their language production over time. Given the evidence and the mechanics of the procedure, we propose that its utility is not constrained by linguistic idiosyncrasies across cultures. Consequently, it has the potential to bypass linguistic barriers to aphasia care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27007060.

What Impacts What: Clinicians' Perspectives of Causality in Aphasia Rehabilitation

PURPOSE

Determining the prognosis of aphasia recovery is an important task for clinicians in the rehabilitation of persons with aphasia. Although there are many variables identified as impactful to aphasia recovery, it is less clear (a) how clinicians perceive causality in aphasia rehabilitation and (b) how prognostic variables interact with each other. This study aimed to understand causal relations between prognostic variables from the clinician perspective.

METHOD

Ratings of perceived causality were obtained from 11 clinicians serving people with aphasia. Participants were presented with 255 directed causal relations (e.g., depression → aphasia severity), representing a total of 18 demographic, diagnostic, and psychosocial variables. Participants rated the perceived causality on a Likert scale from 0 (no causal effect) to 10 (strong causal effect). We also obtained ratings about frequency of access to information about each of the 18 variables.

RESULTS

A perceived causal network showed differences among variables in their perceived causality. There were many causal relations identified, particularly between diagnostic and psychosocial variables. The variables with the strongest perceived causality were predominantly psychosocial variables, including depression, social support, and participation. However, these psychosocial variables were also the variables that clinicians had the least frequent access to information about. There were also notable differences between participants in their perceived causal networks.

CONCLUSIONS

Clinicians hold valuable information about aphasia rehabilitation, including what variables are important to aphasia recovery. Understanding the complexity of interaction among prognostic variables and obtaining data from clinicians about prognostic variables and causality will advance the rehabilitation of aphasia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27105865.

The Flu-ID: A New Evidence-Based Method of Assessing Fluency in Aphasia

PURPOSE

Assessing fluency in aphasia is diagnostically important for determining aphasia type and severity and therapeutically important for determining appropriate treatment targets. However, wide variability in the measures and criteria used to assess fluency, as revealed by a recent survey of clinicians (Gordon & Clough, 2022), results in poor reliability. Furthermore, poor specificity in many fluency measures makes it difficult to identify the underlying impairments. Here, we introduce the Flu-ID Aphasia, an evidence-based tool that provides a more informative method of assessing fluency by capturing the range of behaviors that can affect the flow of speech in aphasia.

METHOD

The development of the Flu-ID was based on prior evidence about factors underlying fluency (Clough & Gordon, 2020; Gordon & Clough, 2020) and clinical perceptions about the measurement of fluency (Gordon & Clough, 2022). Clinical utility is maximized by automated counting of fluency behaviors in an Excel template. Reliability is maximized by outlining thorough guidelines for transcription and coding. Eighteen narrative samples representing a range of fluency were coded independently by the authors to examine the Flu-ID's utility, reliability, and validity.

RESULTS

Overall reliability was very good, with point-to-point agreement of 86% between coders. Ten of the 12 dimensions showed good to excellent reliability. Validity analyses indicated that Flu-ID scores were similar to clinician ratings on some dimensions, but differed on others. Possible reasons and implications of the discrepancies are discussed, along with opportunities for improvement.

CONCLUSIONS

The Flu-ID assesses fluency in aphasia using a consistent and comprehensive set of measures and semi-automated procedures to generate individual fluency profiles. The profiles generated in the current study illustrate how similar ratings of fluency can arise from different underlying impairments. Supplemental materials include an analysis template, extensive guidelines for transcription and coding, a completed sample, and a quick reference guide.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27078199.

Treatment for Childhood Apraxia of Speech: Past, Present, and Future

PURPOSE

The purposes of this review article were to provide an introduction to and "bird's-eye" overview of the current evidence base for treatment of childhood apraxia of speech (CAS), identify some gaps and trends in this rapidly growing literature, and formulate some future research directions, in order to advance the evidence base and clinical practice for children with CAS.

METHOD

Following a brief introduction outlining important concepts, a narrative review of the CAS treatment literature is provided, and trends and future directions are identified based on this review. The review is organized around four fundamental treatment research questions: (a) "Does Treatment X work?", (b) "Does Treatment X work better than Treatment Y?", (c) "For whom does Treatment X work?", and (d) "What does 'work' mean, anyway?"

RESULTS

A wide range of CAS treatments with varying degrees of evidence for efficacy exists. Research is beginning to emerge that compares different treatments and seeks to determine optimal treatment parameters. Few studies to date have explored child-level predictors of treatment response, and the evidence base currently is limited in scope with respect to populations and outcomes studied.

CONCLUSIONS

A growing evidence base supports the efficacy of a number of treatments for CAS. However, many important gaps in the literature were identified that warrant redoubled and sustained research attention. Research is beginning to emerge that addresses treatment optimization, comparison, candidacy, and outcomes. Suggestions for future research are offered, and the concept of a hypothesized pathway was applied to CAS to illustrate how components of an intervention can effect change in a clinical goal and can help guide development and refinement of treatments for children with CAS.

Behavioral Treatment for Speech and Language in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech: A Systematic Review

Primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS) are neurodegenerative syndromes characterized by progressive decline in language or speech. There is a growing number of studies investigating speech-language interventions for PPA/PPAOS. An updated systematic evaluation of the treatment evidence is warranted to inform best clinical practice and guide future treatment research. We systematically reviewed the evidence for behavioral treatment for speech and language in this population. Reviewed articles were published in peer-reviewed journals through 31 May 2021. We evaluated level of evidence, reporting quality, and risk of bias using a modified version of the American Speech-Language Hearing Association (ASHA) Levels of Evidence, an appraisal point system, additional reporting quality and internal/external validity items, and, as appropriate, the Single Case Experimental Design Scale or the Physiotherapy Evidence Database - PsycBITE Rating Scale for Randomized and Non-Randomized Controlled Trials. Results were synthesized using quantitative summaries and narrative review. A total of 103 studies reported treatment outcomes for 626 individuals with PPA; no studies used the diagnostic label PPAOS. Most studies evaluated interventions for word retrieval. The highest-quality evidence was provided by 45 experimental and quasi-experimental studies (16 controlled group studies, 29 single-subject designs). All (k = 45/45) reported improvement on a primary outcome measure; most reported generalization (k = 34/43), maintenance (k = 34/39), or social validity (k = 17/19) of treatment for at least one participant. The available evidence supports speech-language intervention for persons with PPA; however, treatment for PPAOS awaits systematic investigation. Implications and limitations of the evidence and the review are discussed.

Rehabilitation Treatment Specification System: Content and Criterion Validity Across Evidence-Based Voice Therapies for Muscle Tension Dysphonia

PURPOSE

Systematically improving voice therapy outcomes is challenging as the clinician actions (i.e., active ingredients) responsible for improved patient functioning (i.e., targets) are relatively unknown. The theory-driven Rehabilitation Treatment Specification System (RTSS) and standard, voice-specific terminology based on the RTSS (RTSS-Voice) may help address this problem. This qualitative study evaluated if the RTSS and RTSS-Voice can describe four evidence-based voice therapies for muscle tension dysphonia without missing critical aspects (content validity) and identify commonalities and differences across them (criterion validity).

METHOD

Qualitative interviews were completed between the clinicians (protocol experts) who developed and/or popularized the vocal function exercises, laryngeal reposturing, circumlaryngeal massage, and conversation training therapies as well as RTSS experts to produce RTSS specifications that met two consensus criteria: (a) The protocol expert agreed that the specification represented their treatment theory, and (b) the RTSS experts agreed that the specifications correctly adhered to both the RTSS framework and the RTSS-Voice's standard terminology.

RESULTS

The RTSS and RTSS-Voice comprehensively described voice therapy variations across and within the four diverse treatment programs, needing only the addition of one new target: overall auditory-perceptual severity.

CONCLUSIONS

The RTSS and RTSS-Voice exhibited strong content validity. The standard RTSS-Voice terminology helped identify, for the first time, commonalities and differences in treatment ingredients, targets, and mechanisms of action across four treatments developed for the same patient population. In the long term, the RTSS and RTSS-Voice could provide the framework for an ever-growing collection of clinically meaningful and evidence-based therapy algorithms with potential to improve research, education, and clinical care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25537624.

An exploration of anomia rehabilitation in drug-resistant temporal lobe epilepsy

Around 40% of patients who undergo a left temporal lobe epilepsy (LTLE) surgery suffer from anomia (word-finding difficulties), a condition that negatively impacts quality of life. Despite these observations, language rehabilitation is still understudied in LTLE. We assessed the effect of a four-week rehabilitation on four drug-resistant LTLE patients after their surgery. The anomia rehabilitation was based on cognitive descriptions of word finding deficits in LTLE. Its primary ingredients were psycholinguistic tasks and a psychoeducation approach to help patients cope with daily communication issues. We repeatedly assessed naming skills for trained and untrained words, before and during the therapy using an A-B design with follow-up and replication. Subjective anomia complaint and standardized language assessments were also collected. We demonstrated the effectiveness of the rehabilitation program for trained words despite the persistence of seizures. Furthermore, encouraging results were observed for untrained items. Variable changes in anomia complaint were observed. One patient who conducted the protocol as self-rehabilitation responded similarly to the others, despite the different manner of intervention. These results open promising avenues for helping epileptic patients suffering from anomia. For example, this post-operative program could easily be adapted to be conducted preoperatively.

Co-constructed communication therapy for individuals with acquired brain injury: A systematic review

BACKGROUND

Meaningful, varied, joyful conversation is an important therapy target for adults with language or cognitive-communication disorders following acquired brain injury (ABI). However, the complexity of daily communication is often reduced to component parts within intervention programmes, with mixed evidence of generalization to everyday conversation. Interventions targeting co-construction of communication within a dyad offer a structured way in which to retain and treat elements of everyday conversation for individuals and their communication partner (CP). Such interventions exist but they are variably labelled, target different ABI populations and have not been synthesized.

AIMS

To identify the nature, scope and effects of intervention studies targeting co-constructed communication in adults with ABI.

METHOD

This systematic review was completed using PRISMA Guidelines. Six databases (MEDLINE, Embase, CINAHL, Scopus, LLBA, PsychInfo) were searched and 1210 studies were screened. Data were extracted and studies were rated for methodological quality and completeness of reporting. Outcome measures and effects of treatment were collated through descriptive synthesis.

MAIN CONTRIBUTION

This review highlights an emerging evidence base in relation to an intervention approach that targets everyday communication. Co-constructed communication interventions have been reported by 13 studies, from a total of 206 participants with post-stroke aphasia, traumatic brain injury and progressive language impairments. These interventions take a range of formats, including referential communication tasks, retell/recount therapies and communication training programmes. Methodological quality evaluation indicated mostly low-level study designs. Heterogeneity was identified in primary outcome measures, with 28 unique primary outcome measures reported across studies. Most studies demonstrated change in task-specific or broad communication outcome measures.

CONCLUSIONS

Co-constructed communication interventions may offer clinicians a systematic, protocolized, replicable way to target everyday communication for adults with ABI. More high-quality, experimental designs with complete reporting and psychometrically sound outcome measures are needed to strengthen the evidence base.

WHAT THIS PAPER ADDS

What is already known on this subject Everyday conversation is an important therapy target for adults with ABI, but there is mixed evidence of therapy gains generalizing to everyday life. Many interventions reduce conversation to component parts such as naming or sentence construction. A different approach is needed to capture the social, dyadic, interactive and multifaceted nature of conversation. We propose the term 'co-constructed communication interventions' as a therapy genre targeting semi-structured dialogue. These interventions retain elements of everyday conversation (such as multimodal communication and situating tasks within dyads), combined with experimental elements (where stimuli prompt interactions and responses can be scored against normative data). What this paper adds to existing knowledge This review proposes and describes a distinct genre of discourse intervention within the current evidence base with a novel operational definition of 'co-constructed communication'. What are the potential or actual clinical implications of this work? Co-constructed communication interventions directly target elements of everyday communication by situating the therapy goals within a dyadic, interactive, multimodal task. A range of intervention tasks have been identified, including collaborative storytelling and problem-solving. This review will be of interest to clinicians working with adults with ABI; co-constructed communication interventions may offer a useful, replicable way to target aspects of everyday communication. This synthesis of the current evidence base encourages clinicians' informed, evidence-based decisions around these interventions.

Generalization in Aphasia Treatment: A Tutorial for Speech-Language Pathologists

PURPOSE

Generalization has been defined and instantiated in a variety of ways over the last half-century, and this lack of consistency has created challenges for speech-language pathologists to plan for, implement, and measure generalization in aphasia treatment protocols. This tutorial provides an overview of generalization with a focus on how it relates to aphasia intervention, including a synthesis of existing principles of generalization and examples of how these can be embedded in approaches to aphasia treatment in clinical and research settings.

METHOD

Three articles collectively listing 20 principles of generalization formed the foundation for this tutorial. The seminal work of Stokes and Baer (1977) focused attention on generalization in behavioral change following treatment. Two aphasia-specific resources identified principles of generalization in relation to aphasia treatment (Coppens & Patterson, 2018; Thompson, 1989). A selective literature review was conducted to identify evidence-based examples of each of these 20 principles from the extant literature.

RESULTS

Five principles of generalization were synthesized from the original list of 20. Each principle was supported by studies drawn from the aphasia treatment literature to exemplify its application.

CONCLUSIONS

Generalization is an essential aspect of meaningful aphasia intervention. Successful generalization requires the same dedication to strategic planning and outcome measurement as the direct training aspect of intervention. Although not all people with aphasia are likely to benefit equally from each of the principles reviewed herein, our synthesis provides information to consider for maximizing generalization of aphasia treatment outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24714399.

Looking at gesture: The reciprocal influence between gesture and conversation

INTRODUCTION

There is limited research in group communication treatment for people with aphasia but existing studies report benefits of gesture to support conversation. Gesture supports conversation through recipient design features and reducing linguistic demands of lexical retrieval and formulation. Additionally, gesture serves an affiliative function. However, the relationship between gesture use and gestural capacity has not been widely examined. As part of a larger study on group cohesiveness and conversation, this investigation examined the patterns of co-speech gesture within authentic conversations among persons with aphasia to discern the functions of gesture use for the participants, changes in the use of gesture over time, and the relationship between gesture use and gesture ability.

METHODS

Conversation Analysis (CA) was applied in an embedded case-study design. Three participants received an academic semester of group and individual conversation-based treatment according to Facilitating Authentic Conversation (Damico et al., 2015). Four conversations from the treatment were selected and transcribed for multi-modality communication with CA conventions applied, and then cyclically analysed for patterns of gesture.

RESULTS

Participants demonstrated gesture that served social and linguistic functions: ratifying clinicians' proxy turns, turn-allocation, turn repair, relaying novel visual information, emphasizing content, demonstrating affiliation with the prior speaker, demonstrating their assessment others' talk, and demonstrating humor. All three participants showed an increased rate of gesture per turn and increasingly used gesture to repair conversation breakdown. Increased gesture use over the course of the semester coincided with increased scores for pantomime on the Porch Index of Communicative Ability (Porch, 1981, PICA).

CONCLUSION

Individuals with aphasia demonstrated increased use of gesture for varied purposes and improved gestural processing following a semester of conversation-based treatment. This is significant because gesture is an effective support for the repair of conversation breakdown typical of persons with aphasia.

Novel participant-level meta-analytic evidence for AbSANT efficacy

The current study employed interrupted time series (ITS) models to analyze all available (published and unpublished) Abstract Semantic Associative Network Training (AbSANT) data. AbSANT is a semantically focused anomia treatment that targets not only concrete but abstract words, unique among existing anomia treatments. However, evidence to date for the positive effects of AbSANT comes only from small-sample, single-subject design studies, limiting the strength of this evidence and the inferences that can be drawn from it. The statistical power and greater representativeness afforded by this larger aggregated sample enabled us to look for group-level efficacy evidence for AbSANT, examine specific questions about AbSANT's direct training and generalization effects, and identify potential predictors and mechanisms of AbSANT treatment response. We found that across 33 participants from four different data sources, AbSANT appears to be a robust word retrieval therapy protocol, with overall direct training and generalization effects that were more meaningful than exposure effects. Similar to previous smaller-sample study conclusions, we found that in this large sample, training abstract words results not only in larger direct training effects than training concrete words, but also larger generalization effects, suggesting that while AbSANT successfully improves both abstract and concrete word retrieval, it may be better suited for training abstract words. In general, direct training effects were more persistent after treatment ended than generalization effects and effects for concrete words were more persistent than for abstract words. Additionally, the effects of generalization appear to be distinct from the effects of simple exposure to words, and generalization effects are consistent with AbSANT's hypothesized mechanism of action: spreading activation from directly trained concepts to related concepts. Also consistent with this mechanism, we found that milder aphasia and both conceptual and lexical semantic processing ability predicted both direct training and generalization gains, and that executive function was predictive of generalization effects. These factors are thus important to consider when evaluating the appropriateness of AbSANT for individual clients.

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.

Rehabilitation Treatment Specification System: Identifying Barriers, Facilitators, and Strategies for Implementation in Research, Education, and Clinical Care

OBJECTIVE

To explore rehabilitation professionals' experiences and perspectives of barriers and facilitators to implementing the Rehabilitation Treatment Specification System (RTSS) in research, education, and clinical care.

DESIGN

A cross-sectional survey with free text and binary responses was completed by rehabilitation professionals. Survey data were analyzed with a deductive approach of directed content analysis using 2 implementation science frameworks: Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC).

SETTING

Rehabilitation professionals across research, educational, and clinical settings.

PARTICIPANTS

One hundred and eleven rehabilitation professionals-including speech-language pathologists, occupational therapists, physical therapists, physicians, psychologists, researchers, and clinic directors-who explored possible uses or applications of the RTSS for clinical care, education, or research (N=111).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of reported CFIR barriers and facilitators, as well as keywords related to CFIR and ERIC constructs.

RESULTS

The barriers and facilitating strategies differed according to the end-users' intended use, that is, research, education, or clinical. Overall, the 4 most frequently encountered CFIR barriers were the RTSS's complexity, a lack of available RTSS resources, reduced access to knowledge and information about the RTSS, and limited knowledge and beliefs about the RTSS. The ERIC-CFIR matching tool identified 7 ERIC strategies to address these barriers, which include conducting educational meetings, developing and distributing educational materials, accessing new funding, capturing and sharing local knowledge, identifying and preparing champions, and promoting adaptability.

CONCLUSIONS

When attempting to use the RTSS, rehabilitation professionals commonly encountered barriers to understanding and skillfully using the framework. Theory-driven implementation strategies have been identified that have potential for addressing the RTSS's complexity and lack of educational and skill-building resources. Future work can develop the identified implementation strategies and evaluate their effects on RTSS implementation.

Errorless, Errorful, and Retrieval Practice for Naming Treatment in Aphasia: A Scoping Review of Learning Mechanisms and Treatment Ingredients

PURPOSE

Increasingly, mechanisms of learning are being considered during aphasia rehabilitation. Well-characterized learning mechanisms can inform "how" interventions should be administered to maximize the acquisition and retention of treatment gains. This systematic scoping review mapped hypothesized mechanisms of action (MoAs) and treatment ingredients in three learning-based approaches targeting naming in aphasia: errorless learning (ELess), errorful learning (EFul), and retrieval practice (RP). The rehabilitation treatment specification system was leveraged to describe available literature and identify knowledge gaps within a unified framework.

METHOD

PubMed and CINHAL were searched for studies that compared ELess, EFul, and/or RP for naming in aphasia. Independent reviewers extracted data on proposed MoAs, treatment ingredients, and outcomes.

RESULTS

Twelve studies compared ELess and EFul, six studies compared ELess and RP, and one study compared RP and EFul. Hebbian learning, gated Hebbian learning, effortful retrieval, and models of incremental learning via lexical access were proposed as MoAs. To maximize treatment outcomes within theorized MoAs, researchers manipulated study ingredients including cues, scheduling, and feedback. Outcomes in comparative effectiveness studies were examined to identify ingredients that may influence learning. Individual-level variables, such as cognitive and linguistic abilities, may affect treatment response; however, findings were inconsistent across studies.

CONCLUSIONS

Significant knowledge gaps were identified and include (a) which MoAs operate during ELess, EFul, and RP; (b) which ingredients are active and engage specific MoAs; and (c) how individual-level variables may drive treatment administration. Theory-driven research can support or refute MoAs and active ingredients enabling clinicians to modify treatments within theoretical frameworks.

Embedding the rehabilitation treatment specification system (RTSS) into clinical practice: an evaluation of a pilot teaching programme

BACKGROUND

Deficiency in the provision and quality of treatment specification by rehabilitation clinicians impairs the ability to differentiate effective from ineffective elements of treatment. The standardised language of the rehabilitation treatment specification system (RTSS) has been proposed as a countermeasure. To date, there is no evidence of its use in clinical practice and what effect it may have. This study aimed to assess the ability of a pilot teaching programme to embed the RTSS into the clinical practice of an inpatient oncology physiotherapy team. The objectives were to evaluate the teaching programme's effect on; participants' familiarity and perceived benefit of the RTSS, its uptake, participants' clinical reasoning, and their feelings and attitudes towards adopting the RTSS. This study provides an evaluation of the pilot teaching programme which will subsequently inform a larger iteration in an ongoing Health Education England (HEE) project aiming to disseminate and embed the RTSS into physiotherapy practice to improve physiotherapists' treatment specification.

METHODS

A 6-week, multi-modal RTSS pilot teaching programme based upon socio-constructivist theory was delivered to 10 inpatient oncology physiotherapists at a large urban UK trust in 2021. Self-reported measures and clinical case note audits were assessed before and after the RTSS teaching programme to evaluate its effect on RTSS familiarity and perceived benefit, uptake, and clinical reasoning. A post-teaching focus group was undertaken. It was qualitatively analysed using an inductive, independent thematic approach to evaluate clinicians' reflection and adoption.

RESULTS

Ten participants (8F, 29.4(±3.5) years) with variable clinical experience completed the RTSS teaching programme (six 1-hour lecture/case-based-learning sessions weekly) with 85% mean attendance. Nine yielded complete data for analyses, and 7 participated in the focus group. There was significant improvements in self-reported familiarity and confidence using the RTSS. Furthermore, there was a significant effect of the teaching on self-reported clinical reasoning overall and specifically in knowledge and theory application. But this was not reflected in clinicians' uptake of RTSS language, nor in the quality of clinical reasoning emergent in their case notes. Qualitative analyses revealed that while clinicians' conceptual understanding and the relative advantage of using the RTSS in practice was pervasive, they articulated that translating its perceived academic disposition into their clinical practice a challenge.

CONCLUSIONS

The RTSS teaching programme was shown to be effective in improving self-reported measures of clinical reasoning, despite clinical uptake of the RTSS remaining low. Future iterations should be tested across physiotherapy specialisms and in a larger sample with consideration of pedagogical and cultural measures to support the clinical diffusion of the RTSS.

Replication in Evidence-Based Aphasia Treatments

PURPOSE

A critical review was completed to evaluate replication of aphasia treatments that have been vetted and accepted on the American Speech-Language-Hearing Association Practice Portal.

METHOD

The electronic databases Academic Search Premier, ProQuest Central, CINAHL Complete, and ERIC were searched for relevant articles using treatment names as keywords. Coders compared stimuli, material, design, and statistical analysis to pilot treatment approaches. Each study was coded as direct, conceptual, failed, or no replication.

RESULTS

Eighteen treatment approaches were selected for this review. A total of 188 articles met the inclusion criteria. Results revealed that 14 out of 18 treatment approaches were somehow replicated. Direct replications as the most valuable replication type for affirming previously found results were represented in only 1.5% of all studies (3/188). Failed direct replication were at 2% overall (4/188). Conceptual replications were more common across treatment approaches, but also represented at a low level with 22.8% (43/188). The majority of studies were coded as no replication attempt with 73.4%.

DISCUSSION

A critical factor in developing an evidence-based practice is the existence of replicated results for treatment. Replication evaluates the reproducibility of an author's or authors' research methodology and resulting outcomes and helps to ensure that observed treatment effects are reproducible. For an evidence-based treatment to be implemented or used in any clinical setting, it must be one that can be replicated. Direct and conceptual replications of aphasia treatment approaches were found to be alarmingly low considering the importance of replication in our field. It is recommended that replication should become more valued and mainstreamed in aphasia research. A replication database that compiles and maintains treatment manuals for replication purposes can increase the accessibility and acceptability of replications for researchers.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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.

Treatment of the Linguistic and Temporal Components of Lexical Activation to Improve Word Retrieval in Aphasia

Current approaches to treatments for word processing impairments in aphasia emphasize two components to target, the linguistic content, semantic or phonological representations of words, and the processing component, access to and retrieval of those representations. In this study, we explore these two components of a treatment to improve lexical activation that supports access and retrieval of word representations. Five people with aphasia participated. The treatment task was repetition of concrete word pairs after a 5-s response delay which was intended to provide practice in maintaining activation of the words for that 5-s period before reproducing them. Two of the five participants demonstrated a difficulty in maintaining activation of single words in repetition, with accuracy decreasing significantly after the 5-s interval. The treatment was applied to all participants, however, to determine if its benefit was specific to those with the activation maintenance impairment. Results confirmed that the activation maintenance treatment in the context of this repetition task led to more treatment gains for the two participants who demonstrated this specific impairment. They made gains on four of the nine measures compared to improvements on one to two measures for the other participants. A second question addressed in this study was the relative importance of the item component (linguistic content) of the treatment and the processing component, maintenance of activation. To that end, there were two conditions of treatment probes, (1) repeated content for all treatment, immediate post-treatment and 3-month maintenance probes and (2) novel content for probes in these three phases of treatment. Only one participant showed significant improvement in treatment when items were novel for all probes. We discuss the possibility that this outcome reflects a more specific deficit in the temporal processing component of lexical activation compared to the two other participants who showed better performance on probes with repeated items in treatment and post-treatment phases. Clinical implications of this study and directions of future research are discussed.

Evaluating Cognitive-Linguistic Approaches to Interventions for Aphasia Within the Rehabilitation Treatment Specification System

The Rehabilitation Treatment Specification System (RTSS) provides a framework to identify specific components of treatments developed within various rehabilitation disciplines (eg, physical, occupational, or speech-language therapy). Furthermore, this framework offers the opportunity to identify the target and active ingredients of a therapy approach as well as the mechanism of action by which it is hypothesized to effect change in abilities or functions. In this article, we apply the RTSS framework to the characterization of a sample of treatments for aphasia that are based on cognitive-linguistic models of language processing. Our discussion of these applications centers on the benefits of this classification system and additional criteria to consider when evaluating cognitive-linguistic treatments for aphasia.