Effects of bromocriptine in a patient with crossed nonfluent aphasia: a case report

Consistency in Single-Case ABAB Phase Designs: A Systematic Review

The current article presents a systematic review of consistency in single-case ABAB phase designs. We applied the CONsistency of DAta Patterns (CONDAP) measure to a sample of 460 data sets retrieved from 119 applied studies published over the past 50 years. The main purpose was to (a) identify typical CONDAP values found in published ABAB designs and (b) develop interpretational guidelines for CONDAP to be used for future studies to assess the consistency of data patterns from similar phases. The overall distribution of CONDAP values is right-skewed with several extreme values to the right of the center of the distribution. The B-phase CONDAP values fall within a narrower range than the A-phase CONDAP values. Based on the cumulative distribution of CONDAP values, we offer the following interpretational guidelines in terms of consistency: very high, 0 ≤ CONDAP ≤ 0.5; high, 0.5 < CONDAP ≤ 1; medium, 1 < CONDAP < 1.5; low, 1.5 < CONDAP ≤ 2; very low, CONDAP > 2. We give examples of combining CONDAP benchmarks with visual analysis of single-case ABAB phase designs and conclude that the majority of data patterns (41.2%) in published ABAB phase designs is medium consistent.

Adjunctive Approaches to Aphasia Rehabilitation: A Review on Efficacy and Safety

Aphasia is one of the most socially disabling post-stroke deficits. Although traditional therapies have been shown to induce adequate clinical improvement, aphasic symptoms often persist. Therefore, unconventional rehabilitation techniques which act as a substitute or as an adjunct to traditional approaches are urgently needed. The present review provides an overview of the efficacy and safety of the principal approaches which have been proposed over the last twenty years. First, we examined the effectiveness of the pharmacological approach, principally used as an adjunct to language therapy, reporting the mechanism of action of each single drug for the recovery of aphasia. Results are conflicting but promising. Secondly, we discussed the application of Virtual Reality (VR) which has been proven to be useful since it potentiates the ecological validity of the language therapy by using virtual contexts which simulate real-life everyday contexts. Finally, we focused on the use of Transcranial Direct Current Stimulation (tDCS), both discussing its applications at the cortical level and highlighting a new perspective, which considers the possibility to extend the use of tDCS over the motor regions. Although the review reveals an extraordinary variability among the different studies, substantial agreement has been reached on some general principles, such as the necessity to consider tDCS only as an adjunct to traditional language therapy.

Cholinergic Potentiation and Audiovisual Repetition-Imitation Therapy Improve Speech Production and Communication Deficits in a Person with Crossed Aphasia by Inducing Structural Plasticity in White Matter Tracts

Donepezil (DP), a cognitive-enhancing drug targeting the cholinergic system, combined with massed sentence repetition training augmented and speeded up recovery of speech production deficits in patients with chronic conduction aphasia and extensive left hemisphere infarctions (Berthier et al., 2014). Nevertheless, a still unsettled question is whether such improvements correlate with restorative structural changes in gray matter and white matter pathways mediating speech production. In the present study, we used pharmacological magnetic resonance imaging to study treatment-induced brain changes in gray matter and white matter tracts in a right-handed male with chronic conduction aphasia and a right subcortical lesion (crossed aphasia). A single-patient, open-label multiple-baseline design incorporating two different treatments and two post-treatment evaluations was used. The patient received an initial dose of DP (5 mg/day) which was maintained during 4 weeks and then titrated up to 10 mg/day and administered alone (without aphasia therapy) during 8 weeks (Endpoint 1). Thereafter, the drug was combined with an audiovisual repetition-imitation therapy (Look-Listen-Repeat, LLR) during 3 months (Endpoint 2). Language evaluations, diffusion weighted imaging (DWI), and voxel-based morphometry (VBM) were performed at baseline and at both endpoints in JAM and once in 21 healthy control males. Treatment with DP alone and combined with LLR therapy induced marked improvement in aphasia and communication deficits as well as in selected measures of connected speech production, and phrase repetition. The obtained gains in speech production remained well-above baseline scores even 4 months after ending combined therapy. Longitudinal DWI showed structural plasticity in the right frontal aslant tract and direct segment of the arcuate fasciculus with both interventions. VBM revealed no structural changes in other white matter tracts nor in cortical areas linked by these tracts. In conclusion, cholinergic potentiation alone and combined with a model-based aphasia therapy improved language deficits by promoting structural plastic changes in right white matter tracts.

Poststroke Communication Disorders and Dysphagia

Communication and swallowing disorders are common after stroke. Targeted surveillance followed by prompt evaluation and treatment is of paramount importance. The overall goals of rehabilitation for impaired swallowing and communication and swallowing deficits may differ based on the specific deficits caused by the stroke but the main goal is always to improve the patient's everyday interpersonal interactions and optimize participation in society. Fortunately, therapeutic or compensatory interventions can decrease the effects that communication and swallowing deficits have on the quality of life of stroke survivors.

Positive impact of speech therapy in progressive non-fluent aphasia

The aim of this paper is to analyze the effects of intensive speech therapy intervention in a case of progressive non-fluent aphasia (PNFA). This is a dementia syndrome characterized by a progressive deficit in expressive language fluency and syntactic analysis, and by agrammatism and phonemic paraphasias. Although in the early stages there are no alterations in memory, comprehension, or visual processing, personality changes can slightly occur. To analyze the effects of speech therapy in this syndrome, a single case design with pre- and post-test was used. The participant was a male patient of 84 years with PNFA, who for twelve months received weekly speech therapy to stimulate the phonological, lexical and syntactic processing. He underwent neuropsychological assessment in three stages: six months before the onset of therapy, six months after therapy started and after completing 12 months of intervention. Assessment involved linguistic processing, general cognition, neuropsychiatric symptoms, quality of life (QOL) and activities of daily living (ADL). As a result of therapy, the patient showed a slight improvement in language prosody, fluency, and content of spontaneous speech, and a significant improvement in repetition, reading aloud, and oral-phonatory praxis. Other aspects of cognitive functioning (orientation, verbal naming, praxis, and memory) remained stable; ADLs and QoL improved. It is concluded that prolonged speech therapy can improve language processing and have a positive impact on other cognitive and socio-emotional processes in PNFA. This 12-month therapeutic stimulation not only slowed cognitive decline, but allowed to see maintenance of achievements and improvement of symptoms, which can be regarded as a success in PNFA treatment, considering the rapid progression of the disease.

Drug treatment of poststroke aphasia

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

Psycholinguistics of Aphasia Pharmacotherapy: Asking the Right Questions

BACKGROUND

Among the obstacles to demonstrating efficacy of pharmacological intervention for aphasia is quantifying patients' responses to treatment in a statistically valid and reliable manner. In many of the review papers on this topic (e.g., Berthier et al., 2011; de Boissezon, Peran, de Boysson, & Démonet, 2007; Small & Llano, 2009), detailed discussions of various methodological problems are highlighted, with some suggestions on how these shortcomings should be addressed. Given this deep understanding of caveats associated with the experimental design of aphasia pharmacotherapy studies (e.g., Berthier et al., 2011), investigations continue to produce inconsistent results.

AIM

In this review paper we suggest that inclusion of theory-driven linguistic measures in aphasia pharmacotherapy studies would add an important step toward elucidating precise patterns of improvement in language performance resulting from pharmacotherapeutic intervention.

MAIN CONTRIBUTION

We provide a brief review of the clinical approaches currently used in pharmacotherapy studies of aphasia, which often lack psycholinguistic grounding. We then present ways in which psycholinguistic models can complement this approach, offering a rationale for task selection, and as a result, lead to a better understanding of treatment effects. We then follow with an example of how such an integrative approach can be implemented in studies targeting stress reduction in people with aphasia, via beta-blocking agents, as a means to augment language performance, using the psycholinguistic framework of "linguistic anxiety" outlined in Cahana-Amitay et al, 2011 as our guideline.

CONCLUSION

We conclude that the incorporation of psycholinguistic models into aphasia pharmacotherapy studies can increase the resolution with which we can identify functional changes.

Dopaminergic therapy in aphasia

BACKGROUND

The dopaminergic system is involved in a wide range of cognitive functions including motor control, reward, memory, attention, problem-solving and learning. This has stimulated interest in investigating the potential of dopaminergic drugs as cognitive enhancers in aphasic patients.

AIM

To discuss the evidence for the use of dopaminergic agents in patients with aphasia. Levodopa (L-dopa) and the dopamine agonist bromocriptine are the two drugs that have been trialled to date. We discuss, in some detail, the 15 studies that have been published on this topic from the first case report in 1988 to the present (2012), and assess the evidence from each.

MAIN CONTRIBUTION

In addition to summarising the effectiveness of the drugs that have been tried, we examine the possible cognitive mechanisms by which dopaminergic drugs may act on language function and aphasia recovery. Given the wide range of dopaminergic drugs, it is surprising that such a narrow range has been trialled in aphasic patients. Important lessons are to be learned from published studies and we discuss optimal trial designs to help guide future work.

CONCLUSIONS

The evidence for the efficacy of dopaminergic agents in aphasia therapy is mixed. Further trials with better tolerated agents are required. Optimal trial designs with appropriate control groups or blocks should be used. The mechanism of action is unclear, but at the cognitive level the evidence points towards either (re)learning of word-forms or their improved retrieval.

New approach to the rehabilitation of post-stroke focal cognitive syndrome: effect of levodopa combined with speech and language therapy on functional recovery from aphasia

OBJECTIVE

Few studies confirm that pharmacological treatments support post-stroke recovery. The purpose of this study was to determine whether the combination of levodopa with language therapy improves aphasia rehabilitation.

METHODS

We did a prospective, randomized, placebo-controlled, double-blind study in which twenty patients received levodopa before each language therapy session, and an additional 19 received a placebo. Language training was provided during a 3-week period. The efficacy variables were changes from baseline in Boston Diagnostic Aphasia Examination (BDAE) scores.

RESULTS

Patients receiving levodopa experienced greater language improvement in verbal fluency and repetition, compared to patients receiving placebo. Improvement was particularly distinct in patients with anterior lesions.

CONCLUSIONS

Supplementing language therapy with levodopa may improve recovery from aphasia in patients with frontal lesions.

Aphasia therapy on a neuroscience basis

BACKGROUND: Brain research has documented that the cortical mechanisms for language and action are tightly interwoven and, concurrently, new approaches to language therapy in neurological patients are being developed that implement language training in the context of relevant linguistic and non-linguistic actions, therefore taking advantage of the mutual connections of language and action systems in the brain. A further well-known neuroscience principle is that learning at the neuronal level is driven by correlation; consequently, new approaches to language therapy emphasise massed practice in a short time, thus maximising therapy quantity and frequency and, therefore, correlation at the behavioural and neuronal levels. Learned non-use of unsuccessful actions plays a major role in the chronification of neurological deficits, and behavioural approaches to therapy have therefore employed shaping and other learning techniques to counteract such non-use. AIMS: Advances in theoretical and experimental neuroscience have important implications for clinical practice. We exemplify this in the domain of aphasia rehabilitation. MAIN CONTRIBUTION: Whereas classical wisdom had been that aphasia cannot be significantly improved at a chronic stage, we here review evidence that one type of intensive language-action therapy (ILAT)-constraint-induced aphasia therapy-led to significant improvement of language performance in patients with chronic aphasia. We discuss perspectives for further improving speech-language therapy, including drug treatment that may be particularly fruitful when applied in conjunction with behavioural treatment. In a final section we highlight intensive and rapid therapy studies in chronic aphasia as a unique tool for exploring the cortical reorganisation of language. CONCLUSIONS: We conclude that intensive language action therapy is an efficient tool for improving language functions even at chronic stages of aphasia. Therapy studies using this technique can open new perspectives for research into the plasticity of human language circuits.

Dexamphetamine boosts naming treatment effects in chronic aphasia

To date, minimal research has investigated the effect of combining dexamphetamine with standard naming therapy after stroke. The present study used a double-blind, placebo-controlled, multiple baseline, crossover design with two individuals in the chronic stage of stroke recovery. Each individual attended two 4-week blocks of naming therapy (two to three treatment sessions per week). Dexamphetamine (10 mg) was administered at the start of each session during one therapy block, while a placebo was administered during the other therapy block. Therapy progress on treated and untreated items was assessed by a confrontation naming task during and after each therapy block. Both individuals showed greater progress in therapy and maintenance of therapy gains when behavioral treatment was combined with dexamphetamine rather than placebo, although this gain was only statistically significant in one individual. There was no significant improvement on a control task (nonword reading) in either individual. The results provide preliminary evidence that dexamphetamine paired with combined semantic and phonological therapy may be beneficial for the treatment of naming disorders in chronic aphasia.

Disorders of speech and language: aphasia, apraxia and dysarthria

PURPOSE OF REVIEW

We review recent important papers pertaining to acquired aphasia, apraxia of speech and dysarthria with special attention to clinically significant work published in the last 12 months.

RECENT FINDINGS

The role of the contralateral inferior frontal gyrus in language recovery after stroke is controversial, but is an area of active research, particularly in functional imaging studies. Recent treatment studies in poststroke aphasia have shown that intensity of language therapy may be more important than the method of therapy. Some studies have indicated that amphetamines, piracetam and repetitive transcortical magnetic stimulation may be effective adjuncts to speech and language therapy. Treatment studies for poststroke dysarthria indicate that speech supplementation strategies may be effective and deserve further study.

SUMMARY

Recent studies of aphasia provide clues regarding language recovery poststroke, but further studies of the role of the ipsi and contralateral inferior frontal gyrus are necessary, and should be longitudinal. There are relatively few recent studies on the treatment of acquired disorders of speech and language, other than poststroke aphasia.

Pharmakologische Zusatzbehandlung in der Aphasietherapie

Aphasia is one of the most frequent and disabling consequences of stroke. Poor spontaneous recovery and the limited success of conventional speech therapy bring up the question of how current treatment approaches can be improved. Besides increasing training frequency-with daily sessions lasting several hours and high repetition rates of language materials ("massed training")-adjuvant drug therapy may help to increase therapy efficacy. In this article, we illuminate the potential of monoaminergic (bromocriptine, levodopa, d-amphetamine) and cholinergic (donepezil) substances for treating aphasia. For a final evaluation of combined massed training and adjuvant pharmacotherapy, randomized, placebo-controlled (multicenter) clinical trials with sufficient numbers of patients are needed. Furthermore, results of experimental animal studies of functional recovery in brain damage raise hopes that neurotrophic factors or stem cells might find a place in recovery from aphasia in the intermediate future.

Poststroke Aphasia

Aphasia, the loss or impairment of language caused by brain damage, is one of the most devastating cognitive impairments of stroke. Aphasia is present in 21-38% of acute stroke patients and is associated with high short- and long-term morbidity, mortality and expenditure. Recovery from aphasia is possible even in severe cases. While speech-language therapy remains the mainstay treatment of aphasia, the effectiveness of conventional therapies has not been conclusively proved. This has motivated attempts to integrate knowledge from several domains in an effort to plan more rational therapies and to introduce other therapeutic strategies, including the use of intensive language therapy and pharmacological agents. Several placebo-controlled trials suggest that piracetam is effective in recovery from aphasia when started soon after the stroke, but its efficacy vanishes in patients with chronic aphasia. Drugs acting on catecholamine systems (bromocriptine, dexamfetamine) have shown varying degrees of efficacy in case series, open-label studies and placebo-controlled trials. Bromocriptine is useful in acute and chronic aphasias, but its beneficial action appears restricted to nonfluent aphasias with reduced initiation of spontaneous verbal messages. Dexamfetamine improves language function in subacute aphasia and the beneficial effect is maintained in the long term, but its use is restricted to highly selected samples. Pharmacological agents operating on the cholinergic system (e.g. donepezil) have shown promise. Data from single-case studies, case series and an open-label study suggest that donepezil may have beneficial effects on chronic poststroke aphasia. Preliminary evidence suggests that donepezil is well tolerated and its efficacy is maintained in the long term. Randomised controlled trials of donepezil and other cholinergic agents in poststroke aphasia are warranted.

Management of anomia

Anomia is a complex, commonly occurring symptom of aphasia with different underlying causes. A number of behavioral approaches to rehabilitation of anomia have been described. Some are restitutive in nature and attempt to reactivate lexical-semantic or phonological representations to improve word retrieval. Others are intended to reorganize language functions by engaging alternative cognitive systems to mediate word retrieval or by exploiting residual abilities to circumvent the impairment. A better appreciation of the characteristics of an individual's naming deficit may assist the clinician in selecting appropriate interventions for restitution or substitution of function in the management of this disorder.

Stroke and neurodegenerative disorders. 3. stroke: rehabilitation management11An organization with which one or more of the authors is associated has received or will receive financial benefits from a commercial party having a direct financial interest in the results of the research supporting this article. Geis is on the advisory board and the speaker’s bureau of Allergan; she is on the speaker’s bureau of Medtronic

This self-directed learning module highlights common rehabilitation issues in stroke survivors. Topics include spasticity, constraint-induced movement therapy, partial body weight-supported treadmill training, virtual reality training, vestibular retraining, aphasia treatment, and cognitive retraining. It is part of the study chapter on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVES

(a) To identify and review the treatment options for poststroke spasticity; (b) to review the use of body weight-supported treadmill training in stroke patients; (c) to describe virtual reality training as an adjunct in stroke rehabilitation; (d) to review vestibular rehabilitation; (e) to discuss advances in aphasia treatment; (f) to discuss cognitive retraining; and (g) to provide an update on treatment of neglect syndromes.

New developments in stroke rehabilitation

There is increasing evidence that environmental and neuropharmacologic treatments enhance stroke recovery. Functional magnetic resonance imaging and transcranial magnetic stimulation have significantly broadened our understanding of the neuroanatomic relationships involved in recovery from brain injury due to stroke. These tools have also demonstrated the role for pharmacologic enhancement of cortical plasticity coupled with behavioral interventions. Robot-assisted therapy and partial body weight-supported treadmill gait training have demonstrated the role for technologic intervention in the modern neuro-rehabilitation setting. Current research using hemi-field ocular prisms and patching techniques suggest a role in the rehabilitation of hemianopsia and visual neglect. Finally, many advances have been made in the understanding of common stroke complications, such as depression, dysphagia, venous thromboembolic disease, incontinence, and spasticity.