Effectiveness of technologies in the treatment of post-stroke anomia: A systematic review

Asynchronous, online spaced-repetition training alleviates word-finding difficulties in aphasia

Word-finding difficulties for naming everyday objects are often prevalent in aphasia. Traditionally, treating these difficulties has involved repeated drilling of troublesome items with a therapist. Spaced repetition schedules can improve the efficiency of such training. However, spaced repetition in a therapy environment can be both difficult to implement and time-consuming. The current study evaluated the potential utility of automated, asynchronous, online spaced repetition training for the treatment of word-finding difficulties in individuals with aphasia. Twenty-one participants completed a two-week training study, completing approximately 60 minutes per day of asynchronous online drilling. The training items were identified using a pretest, and word-finding difficulties were evaluated both at the end of training (i.e., a post-test) and four weeks later (i.e., a retention test). The trained items were separated into three different spaced-repetition schedules: (1) Short-spacing; (2) Long-spacing; and (3) Adaptive-spacing. At the retention-test, all trained items outperformed non-trained items in terms of accuracy and reaction time. Further, preliminary evidence suggested a potential reaction time advantage for the adaptive-spacing condition. Overall, online, asynchronous spaced repetition training appears to be effective in treating word-finding difficulties in aphasia. Further research will be required to determine if different spaced repetition schedules can be leveraged to enhance this effect.

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

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

Motivation Theory and Practice in Aphasia Rehabilitation: A Scoping Review

PURPOSE

In the aphasia literature, motivation has been described as potentially influencing rehabilitation outcomes, and there are reports that researchers and clinicians have acted to promote it. However, studies directly investigating the range of beliefs and practices surrounding motivation do not exist currently. The purpose of this scoping review is to develop themes related to the beliefs and practices appearing in the recent aphasia literature.

METHOD

Four databases (CINAHL, PsycINFO, PubMed, and Google Scholar) were searched using keywords aphasia and motivation (including derivatives such as motiv*) for articles published between 2009 and 2020. Searches returned 19,731 articles; after deleting duplicates and applying inclusionary criteria, 365 articles remained. In each article, text surrounding the term motivation was highlighted and thematic analysis was applied to these quotations.

RESULTS

Sixteen themes were developed through thematic analysis and placed into two groups. The first group contained five themes suggesting that researchers believed that motivation should be studied and recognized the value of motivation in person(s) with aphasia when participating in research or clinical activities. The second group contained 11 themes reporting diverse beliefs and practices in how motivation is incorporated in research and clinical activities.

CONCLUSIONS

Results from this scoping review suggest that aphasia researchers, clinicians, and persons with aphasia hold beliefs about motivation that can influence clinical and research decisions. In general, beliefs and decisions related to motivation appeared to be guided by intuition rather than theories of motivation. These themes are discussed within the context of three psychological needs proposed by self-determination theory: competency, autonomy, and relatedness. Applying theories of motivation to future study in aphasia rehabilitation will guide work that can provide empirical support for these beliefs.

A Mobile-based Virtual Reality Speech Rehabilitation App for Patients With Aphasia After Stroke: Development and Pilot Usability Study

Background

Stroke has the highest disability-adjusted life-years lost in any disease, and approximately one-third of the patients get aphasia. Computers and tablets are innovative and aid in intensive treatments in speech rehabilitation for patients with aphasia. However, mechanical training limits the help to patients.

Objective

This study aims to provide a framework for an integrated virtual reality (VR) app to provide speech rehabilitation for patients with aphasia.

Methods

The content was generated through an in-depth literature review and discussion with experienced rehabilitation physicians and occupational therapists. We then conducted a 2-round Delphi study with 15 experts from hospitals and universities to rate the content using a 5-point Likert scale. The app was developed by an interdisciplinary team involving VR, medical science of rehabilitation, and therapeutic rehabilitation. Pilot usability testing of this novel app was conducted among 5 patients with aphasia, 5 healthy volunteers, 5 medical staff, and 2 VR experts.

Results

We designed 4 modules of speech rehabilitation: oral expression, auditory comprehension, cognition, and comprehensive application. Our VR-based interactive and intelligent app was developed to provide an alternative option for patients with aphasia. Pilot usability testing revealed user satisfaction with the app.

Conclusions

This study designed and tested a novel VR-based app for speech rehabilitation specifically adapted to patients with aphasia. This will guide other studies to develop a similar program or intelligent system in a clinical setting.

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.

Speech and Language Practitioners' Experiences of Commercially Available Voice-Assisted Technology: Web-Based Survey Study

Background

Speech and language therapy involves the identification, assessment, and treatment of children and adults who have difficulties with communication, eating, drinking, and swallowing. Globally, pressing needs outstrip the availability of qualified practitioners who, of necessity, focus on individuals with advanced needs. The potential of voice-assisted technology (VAT) to assist people with speech impairments is an emerging area of research but empirical work exploring its professional adoption is limited.

Objective

This study aims to explore the professional experiences of speech and language therapists (SaLTs) using VAT with their clients to identify the potential applications and barriers to VAT adoption and thereby inform future directions of research.

Methods

A 23-question survey was distributed to the SaLTs from the United Kingdom using a web-based platform, eliciting both checkbox and free-text responses, to questions on perceptions and any use experiences of VAT. Data were analyzed descriptively with content analysis of free text, providing context to their specific experiences of using VAT in practice, including barriers and opportunities for future use.

Results

A total of 230 UK-based professionals fully completed the survey; most were technologically competent and were aware of commercial VATs (such as Alexa and Google Assistant). However, only 49 (21.3%) SaLTs had used VAT with their clients and described 57 use cases. They reported using VAT with 10 different client groups, such as people with dysarthria and users of augmentative and alternative communication technologies. Of these, almost half (28/57, 49%) used the technology to assist their clients with day-to-day tasks, such as web browsing, setting up reminders, sending messages, and playing music. Many respondents (21/57, 37%) also reported using the technology to improve client speech, to facilitate speech practice at home, and to enhance articulation and volume. Most reported a positive impact of VAT use, stating improved independence (22/57, 39%), accessibility (6/57, 10%), and confidence (5/57, 8%). Some respondents reported increased client communication (5/57, 9%) and sociability (3/57, 5%). Reasons given for not using VAT in practice included lack of opportunity (131/181, 72.4%) and training (63/181, 34.8%). Most respondents (154/181, 85.1%) indicated that they would like to try VAT in the future, stating that it could have a positive impact on their clients’ speech, independence, and confidence.

Conclusions

VAT is used by some UK-based SaLTs to enable communication tasks at home with their clients. However, its wider adoption may be limited by a lack of professional opportunity. Looking forward, additional benefits are promised, as the data show a level of engagement, empowerment, and the possibility of achieving therapeutic outcomes in communication impairment. The disparate responses suggest that this area is ripe for the development of evidence-based clinical practice, starting with a clear definition, outcome measurement, and professional standardization.

Speech-Language Pathologists' Practice Patterns When Designing Home Practice Programs for Persons With Aphasia: A Survey

Purpose We aimed to describe the current practices of speech-language pathologists regarding the creation and implementation of home practice programs for persons with poststroke aphasia. Method Survey participants were American Speech-Language-Hearing Association-certified speech-language pathologists, had 30% of their caseload include persons with aphasia, and had recently created at least two home programs for persons with aphasia. Respondents completed a web-based survey on home program creation, training, technology, and methods for tracking adherence with closed and open-ended questions. Results We analyzed 80 complete surveys. Most of the participants (n = 56) created home programs for greater than 75% of their caseload. Common interventions in home programs addressed functional practice and spoken expression. Participants describe instructional techniques including building skill practice in daily routines and guided practice. Applications of technology and formal mechanisms to monitor adherence were less frequently reported. Various factors were identified as facilitators and barriers to home program creation with environmental support from others and client factors (i.e., motivation, impairments) most evident. Conclusions This study provides insight into speech-language pathologists' home program creation and implementation. Results can be used to consider mechanisms to improve use of and adherence to home programs to further support recovery. Supplemental Material https://doi.org/10.23641/asha.16840204.

Receipt of treatment among a nationally representative sample of US adults with communication disorders

INTRODUCTION

A robust body of literature exists on clinical research outcomes for persons with communication disorders (CD). Comparatively few studies have examined population-based health service outcomes for CD-related services, which capture persons with CDs who may not be part of clinical or administrative data. This is important to describe access to treatment and the factors impacting access. We address this gap, describing four CD-related healthcare outcomes among adults reporting problems with communication (voice, speech, and language): (1) utilization, (2) utilization determinants, (3) professionals providing CD care, and (4) patient-reported service-related outcomes.

METHODS

We conducted a retrospective, cross-sectional study of community-dwelling adults (≥18 years) in the US self-reporting CD on the nationally representative 2012 National Health Interview Survey. Separate analyses examined adults with voice (n = 1,323), speech (n = 658), and language (n = 396) disorders. We used survey weighted logistic regression to assess the likelihood of treatment, controlling for health, disorder, and sociodemographic characteristics; Pearson's chi square was calculated for other outcomes.

RESULTS

An estimated 10% of adults reporting CD described receiving care addressing their CD. Employment, sociodemographic and economic status, health insurance, level of severity, and presence of co-occurring CD were associated with receiving treatment. Over half of respondents with speech and language disorders and less than a fifth of respondents with voice disorders reported receiving care from speech-language pathologists. Adults who received CD-related services reported improvements in activities (52-69% overall) and CD (33-48% overall).

CONCLUSIONS

This population-based study shows that general access to CD services is low. Underserved populations have less access to treatment than their counterparts with more resources. Improving access to CD services requires creative interventions addressing patient and provider needs, as well as healthcare system design. Population-based follow-up studies are necessary to track progress toward improving access to care.

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).

App-based data collection, mental imagery, and naming performance in adults with aphasia

BACKGROUND AND PURPOSE

Naming impairments are often found in aphasia. Combining mHealth technology with mental imagery may offer new insights into novel approaches to naming interventions in persons with aphasia. The aims of this study are to (1) explore whether mental imagery can improve performance during a naming task in adults with aphasia; and, (2) demonstrate the use of app-based data collection for research in aphasia rehabilitation through utilization of an app designed specifically for this study.

MATERIALS AND METHODS

A single subject non-concurrent multiple baseline design across participants was utilized. Four participants with anomic and conduction aphasia were included. Each participant's percentage of naming accuracy was measured before the initiating intervention to establish a baseline level of performance.

RESULTS

Per overlap metrics, two of the participants demonstrated a strong effect in improving naming from baseline to intervention on items using the app. Two participants showed no effect in naming accuracy from the imagery intervention.

CONCLUSION

Some participants showed improvement in naming items following an imagery script, suggesting that this complementary health practice should continue to be explored. Additionally, this study demonstrates the successful use of app-based data collection.

Effectiveness of information and communications technology interventions for stroke survivors and their support people: a systematic review

PURPOSE

To examine the effectiveness of self-directed, off-the-shelf information and communications technology (ICT)-based interventions in improving the quality of life, physical and psychosocial outcomes of community-dwelling stroke survivors and their support persons (SP).

METHODS

Medline, EMBASE, CINAHL and Cochrane databases were searched (2006-19th June 2020) for randomized controlled trials, controlled trials, controlled before and after studies, or interrupted time series studies that met the eligibility criteria. The quality of included studies was assessed. Interventions effectiveness was narratively synthesized, as was participant adherence and acceptability.

RESULTS

Seventeen studies were eligible. Three studies were rated as low risk of bias across all methodological review criteria. Nine studies reported on interventions delivered using self-directed computer programs, two studies utilized internet or web-based support programs and six studies used mobile phone interventions. Few studies reported on intervention acceptability or adherence. Those that did generally reported good acceptability, although adherence was variable. Fifteen studies reported significant positive effects for at least one outcome examined including stroke-specific outcomes, physical outcomes, behavioural outcomes and health service use. No studies found an effect for psychosocial wellbeing.

CONCLUSION

ICT-based interventions are likely to provide benefit to stroke survivors and their SPs. However, there is a need for further robustly designed intervention studies that include larger sample sizes, longer follow-up, and outcomes for SPs.Implications for RehabilitationICT-based interventions with minimal clinician supervision are likely to provide some benefits to stroke survivors and their SPs.There is insufficient evidence to allow recommendations to rehabilitation professionals regarding the type, length and intensity of ICT-based interventions for specific targeted outcomes.Rehabilitation professionals should use professional judgement prior to recommending ICT-based interventions to stroke survivors and their SPs.

A Virtual, Randomized, Control Trial of a Digital Therapeutic for Speech, Language, and Cognitive Intervention in Post-stroke Persons With Aphasia

Background: Post-stroke aphasia is a chronic condition that impacts people's daily functioning and communication for many years after a stroke. Even though these individuals require sustained rehabilitation, they face extra burdens to access care due to shortages in qualified clinicians, insurance limitations and geographic access. There is a need to research alternative means to access intervention remotely, such as in the case of this study using a digital therapeutic.

Objective: To assess the feasibility and clinical efficacy of a virtual speech, language, and cognitive digital therapeutic for individuals with post-stroke aphasia relative to standard of care.

Methods: Thirty two participants completed the study (experimental: average age 59.8 years, 7 female, 10 male, average education: 15.8 years, time post-stroke: 53 months, 15 right handed, 2 left handed; control: average age 64.2 years, 7 female, 8 male, average education: 15.3 years, time post-stroke: 36.1 months, 14 right handed, 1 left handed). Patients in the experimental group received 10 weeks of treatment using a digital therapeutic, Constant Therapy-Research (CT-R), for speech, language, and cognitive therapy, which provides evidence-based, targeted therapy with immediate feedback for users that adjusts therapy difficulty based on their performance. Patients in the control group completed standard of care (SOC) speech-language pathology workbook pages.

Results: This study provides Class II evidence that with the starting baseline WAB-AQ score, adjusted by −0.69 for every year of age, and by 0.122 for every month since stroke, participants in the CT-R group had WAB-AQ scores 6.43 higher than the workbook group at the end of treatment. Additionally, secondary outcome measures included the WAB-Language Quotient, WAB-Cognitive Quotient, Brief Test of Adult Cognition by Telephone (BTACT), and Stroke and Aphasia Quality of Life Scale 39 (SAQOL-39), with significant changes in BTACT verbal fluency subtest and the SAQOL-39 communication and energy scores for both groups.

Conclusions: Overall, this study demonstrates the feasibility of a fully virtual trial for patients with post-stroke aphasia, especially given the ongoing COVID19 pandemic, as well as a safe, tolerable, and efficacious digital therapeutic for language/cognitive rehabilitation.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT04488029.

The feasibility, usability and acceptability of a tablet-based aphasia therapy in the acute phase following stroke

QUESTION

Independent practice via an application with a language exercise program for aphasia, as an add-on to conventional care can be a good solution to intensify aphasia therapy. The aim of this prospective trial was to investigate the feasibility, usability and acceptability of the newly-developed aphasia exercise program in the 'Speech Therapy App (STAPP)' in the acute phase post-stroke.

METHODS

All eligible people with aphasia following stroke (<2 weeks post-stroke) admitted to the Stroke Unit of Ghent University Hospital were recruited in this prospective clinical trial between September 2018 and December 2019. After linguistic assessments and two short training sessions, participants were asked to practice independently with 'STAPP' for at least 30 min/day during hospitalization. Exercises were individually tailored and adjusted if necessary. Outcome was measured by recruitment, adherence and retention rates, usability questionnaires and a visual analogue scale for satisfaction.

RESULTS

Twenty-five (mean age 65 years (SD = 17), 14 females) of 31 eligible people with aphasia were enrolled in this trial (recruitment rate = 81 %). All participants but one (23/24) practiced with the language app until the end of hospitalization (retention rate = 96 %). Ten participants practiced at least 30 min/day (adherence rate = 42 %). Participants reported they learned to work quickly with the app (92 %; agreed/totally agreed), the app was easy to use (88 %), they could work independently (79 %), practiced their language (67 %) and wanted to continue working with the app at home (79 %). Acceptability was high (median satisfaction rate 91 %; IQR = 75-100).

CONCLUSION

The aphasia exercise program in 'STAPP' is feasible to use as an additional rehabilitation tool along with standard of care in the acute phase post-stroke. Further research is needed to assess the efficacy. CLINICAL TRIAL REGISTRATION-URL: https://clinicaltrials.gov/ct2/show/NCT03679637.

[Scoping review of the effectiveness of screen-to-screen-therapy compared to face-to-face-therapy on naming performance for patients with aphasia]

Hintergrund

Etwa 35.000 Menschen in Deutschland erlitten im Jahr 2019 eine Aphasie infolge eines Schlaganfalls. Eine der häufigsten Manifestationen einer Aphasie stellen Wortfindungsstörungen dar. In Zeiten der COVID-19-Pandemie ermöglicht die befristete Zulassung der Videotherapie die Aufrechterhaltung einer sprachtherapeutischen Behandlung. Daraus ergibt sich die Notwendigkeit zu untersuchen, welche Wirksamkeit eine Screen-to-Screen-Therapie über ein Videokonferenzsystem gegenüber einer herkömmlichen Face-to-Face-Therapie bei erwachsenen Aphasiepatient*innen auf die Benennleistungen hat.

Methode

Im Rahmen eines Scoping Reviews wurde eine Literaturrecherche in den Datenbanken Cochrane, Pubmed und Web of Science für den Zeitraum Februar 2010 bis 2020 durchgeführt. Eingeschlossen wurden deutsch- und englischsprachige Studien, welche die Wirksamkeit einer klassischen Face-to-Face-Therapie mit einer Screen-to-Screen-Therapie bei Erwachsenen mit Aphasie miteinander vergleichen und als einen Outcome die Benennleistung erhoben haben. Die Auswahl der Studien erfolgte mithilfe des PRISMA-Flussdiagramms.

Ergebnisse

Insgesamt konnten fünf Studien gefunden werden. Sowohl die Face-to-Face-Therapie als auch die Screen-to-Screen-Therapie zeigten in einer italienischen Crossover-Studie, einer kanadischen randomisierten Studie und einer in Großbritannien durchgeführten quasi-randomisierten Studie signifikante Verbesserungen der Benennleistungen. Keine Verbesserungen wurden für beide Interventionsformen in einer israelischen Crossover-Studie festgestellt. In einer deutschen Vergleichsstudie wurden für die Face-to-Face-Therapie signifikante Verbesserungen der Benennleistungen gemessen, deren Ergebnis sich jedoch nicht signifikant von der Interventionsgruppe der Screen-to-Screen-Therapie unterschied.

Diskussion

In allen eingeschlossenen Studien hatten die Screen-to-Screen-Therapie und die Face-to-Face-Therapie eine vergleichbare Wirksamkeit auf die Benennleistungen. Die Ergebnisse sprechen für die Realisierbarkeit einer Screen-to-Screen-Therapie unter Alltagsbedingungen. Möglicherweise ist diese Therapieform jedoch nicht immer umsetzbar. Barrieren für eine Screen-to-Screen-Therapie können die Bedienung von Technologien sowie Einschränkungen des Gesichtsfeldes infolge eines Neglects sein. Limitationen des Scoping Reviews sind, dass lediglich die Benennleistungen als Outcome betrachtet wurden sowie die geringe Anzahl der eingeschlossenen Studien.

Schlussfolgerung

Im Hinblick auf die Tatsache, dass eine Screen-to-Screen-Therapie während der COVID-19-Pandemie für viele Patient*innen die einzige Möglichkeit einer sprachtherapeutischen Behandlung darstellt, ist es positiv zu werten, dass die Screen-to-Screen-Therapie genauso wirksam ist wie die Face-to-Face-Therapie. Die Screen-to-Screen-Therapie kann einen erweiterten Zugang zu der Gesundheitsversorgung sowie fachlicher Expertise im Gesundheitswesen ermöglichen. Die Aufrechterhaltung der sprachtherapeutischen Versorgung während der COVID-19-Pandemie kann dadurch weitestgehend gesichert werden. Es bedarf weiterer Forschung zu evidenzbasierten Behandlungsmethoden und anwenderorientierten Apps für die Videotherapie.

Multisensory cueing facilitates naming in aphasia

BACKGROUND

Impaired naming is a ubiquitous symptom in all types of aphasia, which often adversely impacts independence, quality of life, and recovery of affected individuals. Previous research has demonstrated that naming can be facilitated by phonological and semantic cueing strategies that are largely incorporated into the treatment of anomic disturbances. Beneficial effects of cueing, whereby naming becomes faster and more accurate, are often attributed to the priming mechanisms occurring within the distributed language network.

OBJECTIVE

We proposed and explored two novel cueing techniques: (1) Silent Visuomotor Cues (SVC), which provided articulatory information of target words presented in the form of silent videos, and (2) Semantic Auditory Cues (SAC), which consisted of acoustic information semantically relevant to target words (ringing for "telephone"). Grounded in neurophysiological evidence, we hypothesized that both SVC and SAC might aid communicative effectiveness possibly by triggering activity in perceptual and semantic language regions, respectively.

METHODS

Ten participants with chronic non-fluent aphasia were recruited for a longitudinal clinical intervention. Participants were split into dyads (i.e., five pairs of two participants) and required to engage in a turn-based peer-to-peer language game using the Rehabilitation Gaming System for aphasia (RGSa). The objective of the RGSa sessions was to practice communicative acts, such as making a request. We administered SVCs and SACs in a pseudorandomized manner at the moment when the active player selected the object to be requested from the interlocutor. For the analysis, we compared the times from selection to the reception of the desired object between cued and non-cued trials.

RESULTS

Naming accuracy, as measured by a standard clinical scale, significantly improved for all stimuli at each evaluation point, including the follow-up. Moreover, the results yielded beneficial effects of both SVC and SAC cues on word naming, especially at the early intervention sessions when the exposure to the target lexicon was infrequent.

CONCLUSIONS

This study supports the efficacy of the proposed cueing strategies which could be integrated into the clinic or mobile technology to aid naming even at the chronic stages of aphasia. These findings are consistent with sensorimotor accounts of language processing, suggesting a coupling between language, motor, and semantic brain regions.

TRIAL REGISTRATION

NCT02928822 . Registered 30 May 2016.

Follow-Up in Aphasia Caused by Acute Stroke in a Prospective, Randomized, Clinical, and Experimental Controlled Noninvasive Study With an iPad-Based App (Neolexon®): Study Protocol of the Lexi Study

Rationale: Treatment of aphasia is still challenging for clinicians and patients. So far, there is proven evidence for "face-to-face" speech therapy. However, the digital age potentially offers new and complementary strategies that may add to treatment outcome in a cost-effective way. Neolexon® is a commercial tablet-based software for treatment of aphasia, which can be applied with the help of a therapist or as self-training by the patient. Aims and hypothesis: In the Lexi study, we aim to determine whether treatment with Neolexon® is superior to standard therapy in acute post-stroke aphasia. Sample size estimates: A sample size of 180 patients, 90 for each group, will be included with an assumed dropout rate of ~20%. Methods and design: Prospective, randomized, parallel group, open-label, blinded-endpoint clinical, and experimental controlled non-invasive trial (PROBE). Adult German native speakers with acute aphasia after stroke are included. Computer-generated, blocked, and stratified randomization by aphasia severity will assign patients to one of two groups: 4 weeks of either standard logopedic speech therapy or logopedic speech therapy with the app version of Neolexon®. Both groups will be instructed in self-training: the frequency and duration of self-training will be documented. Screening for aphasia will be performed using the Language Screening Test (LAST). The severity of aphasia in general and in subitems will be assessed using the Bielefelder Aphasie Screening (BIAS) and the Aphasia Check List (ACL). Follow-up will be assessed after 3 months. Study outcomes: Based on the consensus in our study team, we considered a 10% mean difference in the change of percentile rank (PR) of BIAS to be a minimal and clinically important difference. The primary endpoint is defined as a significant difference in BIAS comparing the two groups. Differences in quality of life, Beck Depression Inventory (BDI), and modified Ranking Scale (mRS) will be evaluated as secondary outcome parameters. Discussion: This trial will determine whether speech therapy with the use of Neolexon® is superior to standard logopedic therapy. Subgroups with the greatest response to Neolexon® will be described. The trial was prospectively registered on the "EU Clinical Trials Register" (NCT04080817).

How Well Do We Use Our Technology? Examining iPad Navigation Skills in Individuals With Aphasia and Older Adults

Purpose Technology is increasingly being used in rehabilitation, yet exposure and comfort with technology varies across individuals, particularly among older adults. There are limited ways to evaluate comfort with technology or teach people how to use technological devices. The objective of the current study was to develop an iPad task battery and evaluate performance by individuals with aphasia and older adults, further examining whether participants could learn to improve performance with written, verbal, and visual instructions. Method Thirty-two participants completed this study (16 with poststroke aphasia and 16 older adult controls). Participants completed 3 phases of testing: (a) baseline evaluation of performance of an iPad task battery, (b) teaching and practice of unknown tasks, and (c) retention evaluation. Participants were scored on accuracy, speed, and efficiency in each phase. Results were evaluated as a function of demographic and cognitive-linguistic variables. Results Results demonstrate that variability arises in people's abilities to perform tasks on an iPad and that cognitive skills such as executive functions, planning, and visuospatial attention relate to baseline scores of performance. The majority of participants with aphasia showed evidence of retaining information learned in the teaching and practice phase; however, they showed a lower percentage of retained lessons relative to controls. Conclusions Findings support the hypothesis that technology abilities vary among individuals with and without aphasia. Evaluating technology ability and the ability to learn technology is an important component to consider when prescribing tablet-based therapies.

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

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

Therapist-Guided Tablet-Based Telerehabilitation for Patients With Aphasia: Proof-of-Concept and Usability Study

BACKGROUND

Aphasia is the loss or impairment of language functions and affects everyday social life. The disorder leads to the inability to understand and be understood in both written and verbal communication and affects the linguistic modalities of auditory comprehension, verbal expression, reading, and writing. Due to heterogeneity of the impairment, therapy must be adapted individually and dynamically to patient needs. An important factor for successful aphasia therapy is dose and intensity of therapy. Tablet computer-based apps are a promising treatment method that allows patients to train independently at home, is well accepted, and is known to be beneficial for patients. In addition, it has been shown to ease the burden of therapists.

OBJECTIVE

The aim of this project was to develop an adaptive multimodal system that enables aphasic patients to train at home using language-related tasks autonomously, allows therapists to remotely assign individualized tasks in an easy and time-efficient manner, and tracks the patient's progress as well as creation of new individual exercises.

METHODS

The system consists of two main parts: (1) the patient's interface, which allows the patient to exercise, and (2) the therapist's interface, which allows the therapist to assign new exercises to the patient and supervise the patient's progress. The pool of exercises is based on a hierarchical language structure. Using questionnaires, therapists and patients evaluated the system in terms of usability (ie, System Usability Scale) and motivation (ie, adapted Intrinsic Motivation Inventory).

RESULTS

A total of 11 speech and language therapists (age: mean 28, SD 7 years) and 15 patients (age: mean 53, SD 10 years) diagnosed with aphasia participated in this study. Patients rated the Bern Aphasia App in terms of usability (scale 0-100) as excellent (score >70; Z=-1.90; P=.03) and therapists rated the app as good (score >85; Z=-1.75; P=.04). Furthermore, patients enjoyed (scale 0-6) solving the exercises (score>3; mean 3.5, SD 0.40; Z=-1.66; P=.049).

CONCLUSIONS

Based on the questionnaire scores, the system is well accepted and simple to use for patients and therapists. Furthermore, the new tablet computer-based app and the hierarchical language exercise structure allow patients with different types of aphasia to train with different doses and intensities independently at home. Thus, the novel system has potential for treatment of patients with aphasia as a supplement to face-to-face therapy.

Efficacy of a self-administered treatment using a smart tablet to improve functional vocabulary in post-stroke aphasia: a case-series study

BACKGROUND

Aphasia is an acquired language disorder that occurs secondary to brain injury, such as stroke. It causes communication difficulties that have a significant impact on quality of life and social relationships. Although the efficacy of speech-language therapy has been clearly demonstrated in this population, long-term services are currently limited due to logistical and financial constraints. In this context, the potential contribution of technology, such as smart tablets, is worth exploring, especially to improve vocabulary that is relevant in daily life.

AIMS

The main aim was to investigate the efficacy of a self-administered treatment using a smart tablet to improve naming of functional words in post-stroke anomia.

METHODS & PROCEDURES

Four adults with post-stroke aphasia took part in the study. An ABA design with multiple baselines was used to compare naming performances for four equivalent lists: (1) trained with functional words chosen with the participant; (2) trained with words randomly chosen from a picture database; (3) exposed but not trained; and (4) not exposed (control).

OUTCOMES & RESULTS

For all participants, the treatment self-administered at home (four times/week for 4 weeks) resulted in a significant improvement for both sets of trained words that was maintained 2 months after the end of treatment. Moreover, in two participants, evidence of generalization to conversation was found.

CONCLUSIONS & IMPLICATIONS

This study confirms the efficacy of using smart tablets to improve naming in post-stroke aphasia. Although more studies are needed, the use of new technologies is unquestionably a promising approach to improve communication skills in people with aphasia, especially by targeting vocabulary that is relevant to them in their daily lives.

What speech and language therapy do community dwelling stroke survivors with aphasia receive in the UK?

Background

Speech and language therapy provision for aphasia (a language disorder) post stroke has been studied over time through surveys completed by speech and language therapists. This paper revisits provision based on what was received by 278 patients in 21 UK speech and language therapy departments in 2014–2016.

Aims

To explore the speech and language therapy received by community dwelling people with post stroke aphasia in the UK.

Methods and procedures

A quantitative content analysis was conducted by two speech and language therapist researchers. Therapy goals recorded were coded into categories and subcategories. Descriptive statistics were used to identify the frequency with which goal categories were targeted, average therapy time received, length and frequency of therapy sessions, personnel involved and mode of delivery.

Outcomes and results

Forty-five percent of participants were in receipt of therapy in the three month window observed. Six goal categories were identified. Rehabilitation was the most frequent (60%) followed by enabling (17.2%), review (4.3%), assessment (3.6%), supportive (3.5%) and activity to support therapy (2.8%). The median amount of therapy received in three months was 6.3 hours at an average of one 60-minute session every two weeks. Seventy-seven percent of therapy sessions were delivered by qualified speech and language therapists and 23% by assistants. Ninety percent of sessions were one to one, face to face sessions whilst 9.5% were group sessions.

Discussion

In line with previous reports, speech and language therapy for community dwelling stroke survivors with aphasia is restricted. Rehabilitation is a large focus of therapy but the intensity and dose with which it is provided is substantially lower than that required for an effective outcome. Despite this, one to one face to face therapy is favoured. More efficient methods to support more therapeutic doses of therapy are not commonly used in routine clinical services.

Effects of a Tablet-Based Home Practice Program With Telepractice on Treatment Outcomes in Chronic Aphasia

PURPOSE

The aim of this study was to determine if a tablet-based home practice program with weekly telepractice support could enable long-term maintenance of recent treatment gains and foster new language gains in poststroke aphasia.

METHOD

In a pre-post group study of home practice outcomes, 21 individuals with chronic aphasia were examined before and after a 6-month home practice phase and again at follow-up 4 months later. The main outcome measure studied was change in naming previously treated or untreated, practiced or unpracticed pictures of objects and actions. Individualized home practice programs were created in iBooks Author with semantic, phonemic, and orthographic cueing in pictures, words, and videos in order to facilitate naming of previously treated or untreated pictures.

RESULTS

Home practice was effective for all participants with severity moderating treatment effects, such that individuals with the most severe aphasia made and maintained fewer gains. There was a negative relationship between the amount of training required for iPad proficiency and improvements on practiced and unpracticed pictures and a positive relationship between practice compliance and same improvements.

CONCLUSION

Unsupervised home practice with weekly video teleconferencing support is effective. This study demonstrates that even individuals with chronic severe aphasia, including those with no prior smart device or even computer experience, can attain independent proficiency to continue practicing and improving their language skills beyond therapy discharge. This could represent a low-cost therapy option for individuals without insurance coverage and/or those for whom mobility is an obstacle to obtaining traditional aphasia therapy.

Special issue on technology and neuropsychological rehabilitation: Overview and reflections on ways to conduct future studies and support clinical practice

In this editorial, we wish to highlight and reflect on research advances presented in the articles comprising this special issue on technology and neuropsychological rehabilitation, which happens to be published more than a decade after the first special issue on the subject. In 2004, the journal recognised the great potential of information technology for increasing the support provided to people with cognitive deficits, and published emerging state-of-the art practices in the field. Since that time, research and technology have made tremendous progress, and the influence of information technology on research methods has transformed the field of neurorehabilitation. The aim of this editorial is thus to shed light on methodological and conceptual issues requiring further attention from researchers and clinicians in the fields of neuropsychological rehabilitation and technology, and to stimulate debate on promising avenues in clinical research.