High-Intensity Aphasia Intervention Is Minimally Fatiguing in Chronic Aphasia: An Analysis of Participant Self-Ratings From a Large Randomized Controlled Trial.

BACKGROUND: High-intensity therapy is recommended in current treatment guidelines for chronic poststroke aphasia. Yet, little is known about fatigue levels induced by treatment, which could interfere with rehabilitation outcomes. We analyzed fatigue experienced by people with chronic aphasia (>6 months) during high-dose interventions at 2 intensities. METHODS: A retrospective observational analysis was conducted on self-rated fatigue levels of people with chronic aphasia (N=173) collected during a previously published large randomized controlled trial of 2 treatments: constraint-induced aphasia therapy plus and multi-modality aphasia therapy. Interventions were administered at a higher intensity (30 hours over 2 weeks) or lower intensity (30 hours over 5 weeks). Participants rated their fatigue on an 11-point scale before and after each day of therapy. Data were analyzed using Bayesian ordinal multilevel models. Specifically, we considered changes in self-rated participant fatigue across a therapy day and over the intervention period. RESULTS: Data from 144 participants was analyzed. Participants were English speakers from Australia or New Zealand (mean age, 62 [range, 18-88] years) with 102 men and 42 women. Most had mild (n=115) or moderate (n=52) poststroke aphasia. Median ratings of the level of fatigue by people with aphasia were low (1 on a 0-10-point scale) at the beginning of the day. Ratings increased slightly (+1.0) each day after intervention, with marginally lower increases in the lower intensity schedule. There was no evidence of accumulating fatigue over the 2- or 5-week interventions. CONCLUSIONS: Findings suggest that intensive intervention was not associated with large increases in fatigue for people with chronic aphasia enrolled in the COMPARE trial (Constraint-Induced or Multimodality Personalised Aphasia Rehabilitation). Fatigue did not change across the course of the intervention. This study provides evidence that intensive treatment was minimally fatiguing for stroke survivors with chronic aphasia, suggesting that fatigue is not a barrier to high-intensity treatment.

Functional neuroimaging and behavioral correlates of multisite tDCS as an add-on to language training in a person with post-stroke non-fluent aphasia: a year-long case study.

Mary, who experienced non-fluent aphasia as a result of an ischemic stroke, received 10 years of personalized language training (LT), resulting in transient enhancements in speech and comprehension. To enhance these effects, multisite transcranial Direct Current Stimulation (tDCS) was added to her LT regimen for 15 sessions. Assessment using the Reliable Change Index showed that this combination improved her left inferior frontal connectivity and speech production for two months and significantly improved comprehension after one month. The results indicate that using multisite transcranial direct current stimulation (tDCS) can improve the effectiveness of language therapy (LT) for individuals with non-fluent aphasia.

White Matter Hyperintensities as a Predictor of Aphasia Recovery.

OBJECTIVE: To examine the relation between baseline white matter hyperintensities (WMH) and change in naming, content production, and efficiency after treatment in subacute aphasia. We hypothesized that more severe baseline WMH would result in less improvement with treatment. DESIGN: Retrospective analysis of a cohort from a double-blind randomized controlled trial (RCT). SETTING: Outpatient clinical setting or participant home. PARTICIPANTS: We retrospectively reviewed imaging and behavioral data for 52 participants with subacute aphasia due to left-hemisphere ischemic stroke enrolled in the RCT. RCT inclusion criteria: English proficiency, normal/corrected-to-normal hearing/vision, and no history of neurologic conditions other than the stroke resulting aphasia. One participant with a chronic right-hemisphere lesion was retained as she presented with no residual deficits on neurologic examination. Individuals with scalp sensitivities or on medications that lower seizure threshold or any N-methyl-D-aspartate (NMDA) antagonists were excluded. Of the 52 participants, for this analysis, 2 were excluded for not having a magnetic resonance imaging, and 7 were excluded for not participating in treatment or pre/post assessment for at least 1 outcome, resulting in final sample of 43 participants (20 women sex, M [SD] age=64.4 [11.9] and M [SD] education=14.9 [3.1] years). INTERVENTIONS: Participants received 15 sessions (2-3 times/week) of computerized lexical-semantic (ie, verification) treatment with [sham/active] transcranial direct current stimulation (tDCS). Sessions were approximately 45 minutes each (tDCS for first 20 minutes). MAIN OUTCOME MEASURES: Naming accuracy, content units (CUs, a measure of semantically accurate production), and efficiency (ie, syllables/CU) on a picture description task. RESULTS: Periventricular WMH severity was independently associated with recovery in picture naming for the active tDCS group. Deep WMH severity was associated with recovery for CU production for the sham tDCS group. CONCLUSION: Baseline periventricular and deep WMH, among other factors, may be an important consideration for prognosis and treatment planning, especially when considered in conjunction with tDCS treatment.

Smartphone use as an efficient tool to improve anomia in primary progressive aphasia.

Cognitive interventions are helpful in the non-pharmacological management of Primary progressive aphasia (PPA) and other neurodegenerative disorders of cognition, by helping patients to compensate for their cognitive deficits and improve their functional independence. In this study, we examined the effectiveness of cognitive rehabilitation based on the use of mobile device technology in PPA. The aim of this research study was to determine if BL, a patient with semantic variant PPA (svPPA) and severe anomia, was able to learn using specific smartphone functions and an application to reduce her word finding difficulties. She was trained during the intervention sessions on a list of target pictures to measure changes in picture naming performance. Errorless learning was applied during learning. BL quickly learned to use smartphone functions and the application over the course of the intervention. She significantly improved her anomia for trained pictures, and to a lesser extent for untrained semantically related pictures. Picture naming performance was maintained six months after the intervention, and she continued to use her smartphone regularly to communicate with family members and friends. This study confirms that smartphone use can be learned in PPA, which can help reduce the symptoms of anomia and improve communication skills.

Understanding and Addressing the Individualized Emotional Impact of Aphasia: A Framework for Speech-Language Pathologists.

Emotion plays an integral role in communication and has long been considered relevant to aphasia rehabilitation. Speech-language pathologists (SLPs), however, may sometimes wonder how or whether to address emotional responses. The purpose of this article was to (1) present a framework that clinicians can use to understand individualized emotional responses in aphasia and (2) discuss examples of how the framework informs practical strategies that SLPs can use to provide emotional support to people with aphasia (PWA). Drawing upon a cognitive-motivational-relational theory of emotions perspective combined with emerging research in aphasia, I show that emotion impacts and is impacted by both language processing and social participation, but this impact should be interpreted in light of individual variability. Personal characteristics, environmental conditions, and cognitive appraisal, considered within a specific cultural context, help account for individualized emotional responses. SLPs should consider interactions among emotional response, language processing, and social participation in aphasia while recognizing each person's unique perception of the situation and resources to cope with it. Additionally, the presented framework provides insights about how SLPs could offer emotional support to PWA. Specific examples related to harnessing situational demands to improve communication, employing active listening, facilitating reappraisal, and strengthening social support are discussed.

"Good," "Hopeless," and "Alright": People with Aphasia Expressing Their Opinions on Their Rehabilitation Experiences.

Treatment for people with aphasia mainly concentrates on facilitating the communication of needs or providing facts. This focus is in danger of downplaying the significance of the expression of attitudes and emotion. Evaluative expression is critical for recreating identity and social interaction. However, the linguistic expression of emotions following aphasia has been insufficiently explored. This study aimed to determine which semantic-lexical devices people with aphasia used to express their opinions and views about their clinicians and rehabilitation. In-depth interviews with 50 people with aphasia describing their emotions during their rehabilitation were analyzed using the appraisal framework comprising appreciation, affect, and judgment. Speakers also graded their attitudes toward people, things, or events. Almost half of instances expressed appreciation, over one-third expressed judgment, and about 16% expressed affect. Amplification of emotions was used frequently, in over 40% of instances. Affective difficulties following aphasia and other brain injuries are among the most important factors for rehabilitation, social reintegration, and the burden on family members. To ameliorate these issues, the focus of rehabilitation in aphasia needs to shift from expressing needs toward facilitating the expression of opinions and feelings and providing people with aphasia with the opportunities and means to express their views on their healthcare.

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.

Fatigue Influences Social Participation in Aphasia: A Cross-sectional and Retrospective Study Using Patient-Reported Measures.

OBJECTIVE: To examine associations between social participation, fatigue, and aphasia severity using patient-reported outcome measures and to examine associations between demographic/diagnostic variables and fatigue in people with aphasia. DESIGN: Retrospective analysis of patient-reported outcome measures using a Bayesian framework. SETTING: Urban rehabilitation research hospital. PARTICIPANTS: 67 participants (N=67) with chronic aphasia (mean age=54.1 years) as a consequence of stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ability to Participate in Social Roles and Activities, Fatigue, and Global Health Questionnaire scales from the Patient-Reported Outcomes Measurement Information System initiative and the Western Aphasia Battery-Revised. We hypothesized an association between social participation and fatigue in people with aphasia. RESULTS: People with aphasia with higher fatigue levels tended to report less social participation. Also, people with aphasia who were a longer time post-stroke tended to report higher social participation. People with aphasia who reported better physical health were more likely to report higher social participation. CONCLUSIONS: There is an association between fatigue and social participation in people with aphasia. Fatigue should be considered in clinical assessments and treatments for this population.

A survey of speech pathologists' opinions about the prospective acceptability of an online implementation platform for aphasia services.

BACKGROUND: Online knowledge translation (KT) approaches are becoming increasingly prevalent within healthcare due to their accessibility and facilitation of international support networks. Online platforms enable timely and far-reaching dissemination of current evidence and best-practice recommendations. Although there is potential to improve the uptake of rehabilitation guidelines, it is essential to consider the acceptability of online approaches to healthcare professionals to ensure their successful integration within everyday clinical settings. AIMS: To establish the prospective acceptability of a theoretically informed online intervention for speech pathologists, Aphasia Nexus: Connecting Evidence to Practice, that aims to facilitate the implementation of aphasia best practice. METHODS & PROCEDURES: A mixed-methods multinational electronic survey based on the Theoretical Framework of Acceptability (TFA) completed by aphasia researchers and clinicians. OUTCOMES & RESULTS: A total of 43 participants completed the survey with 91% (n = 39) indicating that they would use Aphasia Nexus. Understanding the intervention and how it works (intervention coherence as per the TFA) was the key factor influencing the likelihood of integration within everyday clinical practice. Participants identified potential areas where the intervention could influence service change and also recommended further design and content changes to improve the intervention. CONCLUSIONS & IMPLICATIONS: Aphasia Nexus is an acceptable platform for further feasibility testing in the form of a pilot trial within an Australian-based health service. The study progresses the theory of TFA as it was a valuable framework facilitating the identification of prominent factors influencing acceptability. The study also informs further intervention refinements in preparation for the next stage of research. WHAT THIS PAPER ADDS: What is already known on the subject Online strategies have the potential to enhance KT and promote the uptake of rehabilitation guidelines. An online intervention, however, can only be effective if implemented well. For this reason, it is essential to establish the acceptability of online interventions to the intended recipients and therefore increase the likelihood of successful implementation. What this paper adds to existing knowledge This study used a theoretically based framework to establish the acceptability of an online implementation intervention, Aphasia Nexus, to multinational aphasia clinicians and researchers. It demonstrated the value in identifying the prominent factors influencing acceptability to inform further intervention refinements and warrant continuing research. What are the potential or actual clinical implications of this work? Speech pathologists should use online platforms to drive the implementation of best practice on an international scale. It is important for clinicians to have an in-depth understanding of online interventions and how they work to enhance their successful uptake into routine clinical practice. Aphasia Nexus is an acceptable online platform for implementing best practice in aphasia.

Which blueberries are better value? The development and validation of the functional numeracy assessment for adults with aphasia.

BACKGROUND: People with aphasia (PWA) can experience functional numeracy difficulties, that is, problems understanding or using numbers in everyday life, which can have numerous negative impacts on their daily lives. There is growing interest in designing functional numeracy interventions for PWA; however, there are limited suitable assessments available to monitor the impact of these interventions. Existing functional numeracy assessments lack breadth and are not designed to be accessible for PWA, potentially confounding their performance. Additionally, they do not include real-life demands, such as time pressure, which may affect their ecological validity. Thus, there is a crucial need for a new assessment to facilitate further research of PWA's functional numeracy. AIMS: To develop, validate and pilot a wide-ranging, aphasia-friendly functional numeracy assessment to investigate how functional numeracy is impacted by aphasia severity and time pressure demands, and to explore predictors of PWA's functional numeracy. METHODS & PROCEDURES: To develop the Functional Numeracy Assessment (FNA), 38 items inspired by the General Health Numeracy Test (GHNT) and Excellence Gateway were adapted for suitability for PWA and entered in a computerized psychometric-style test. The final 23 items (FNA23) were selected based on 213 neurotypical controls' performance, and controlled for difficulty, response modality and required numeracy skills. Aphasia-friendly adaptations of the GHNT and Subjective Numeracy Scale were used to examine the FNA23's concurrent validity. Internal consistency reliability and interrater reliability (for spoken responses) were also examined. A novel Time Pressure Task was created by slight adaptation of seven FNA23 questions to explore the effects of time pressure on functional numeracy performance. A total of 20 PWA and 102 controls completed all measures on an online testing platform. OUTCOMES & RESULTS: The FNA23 demonstrated acceptable internal consistency reliability (KR-20 = 0.81) and perfect interrater reliability (for spoken responses). FNA23 and GHNT scores were positively associated, suggesting satisfactory concurrent validity. PWA demonstrated poorer functional numeracy than controls and took longer to complete assessments, indicating that aphasia impacts functional numeracy. Time pressure did not significantly impact performance. PWA demonstrated a wide range of functional numeracy abilities, with some performing similarly to controls. CONCLUSIONS & IMPLICATIONS: The FNA23 is a wide-ranging, valid and reliable assessment which, with further development, will be a useful tool to identify and monitor PWA's functional numeracy difficulties in research and clinical practice. Considering PWA's widespread functional numeracy difficulties evidenced by this study, all PWA would likely benefit from routine evaluation for functional numeracy difficulties as part of their neurorehabilitation journeys. WHAT THIS PAPER ADDS: What is already known on this subject Few studies have investigated functional numeracy difficulties in PWA. No published functional numeracy assessments exist that have been specifically designed to be accessible for PWA. What this paper adds to existing knowledge The newly developed FNA23 is a valid and reliable tool to extensively assess PWA's functional numeracy. This study confirmed previous findings of widespread functional numeracy difficulties in PWA that are related to their aphasia severity. What are the potential or actual clinical implications of this work? The FNA23 can be used to assess PWA's functional numeracy to inform areas of strengths and difficulties to target in intervention, and to monitor progress towards achieving intervention objectives. All PWA should be routinely evaluated for functional numeracy difficulties.

'It's been an extraordinary journey': Experience of engagement from the perspectives of people with post-stroke aphasia.

BACKGROUND: Engagement is recognized as an important factor in aphasia treatment response and outcomes, yet gaps remain in our understanding of engagement and practices that promote engagement from the client perspective. AIMS: The purpose of this phenomenological study was to explore how clients with aphasia experience engagement during their inpatient aphasia rehabilitation. METHODS & PROCEDURES: An interpretative phenomenological analysis approach guided the study design and analysis. Data were collected through in-depth interviews with nine clients with aphasia, recruited through purposive sampling, during their inpatient rehabilitation admission. Analysis was completed using a variety of analytic techniques including coding, memoing, triangulation between coders and team discussion. OUTCOMES & RESULTS: The analysis revealed that for clients with aphasia in the acute phrase of recovery, the rehabilitation process resembles travelling on a journey through a foreign land. Successful engagement in the journey was accomplished when one had a therapist who served as a trusted guide and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable. CONCLUSIONS & IMPLICATIONS: Engagement is a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. Findings from this work have implications for measuring engagement, training student clinicians to be skilled facilitators in engaging their clients and implementing person-centred practices that promote engagement within clinical settings. WHAT THIS PAPER ADDS: What is already known on the subject Engagement is recognized as an important factor in rehabilitation treatment response and outcomes. Prior literature suggests that the therapist plays a critical role in facilitating engagement within the client-provider relationship. Communication impairments associated with aphasia may negatively impact a client's ability to develop interpersonal connections and participate in the rehabilitation process. There is a dearth of research directly exploring the topic of engagement in aphasia rehabilitation, particularly from the perspective of clients with aphasia. Capturing the client perspective can provide novel insights regarding practices to foster and maintain engagement in aphasia rehabilitation. What this paper adds to existing knowledge This interpretative phenomenological study revealed that for individuals with aphasia in the acute phase of recovery, the rehabilitation process resembles travelling on a sudden and foreign journey. Successful engagement in the journey was accomplished when one had a therapist who served as a 'trusted guide' and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable. Through the client experience, engagement is seen as a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. What are the potential or actual clinical implications of this work? The current study highlights the complexity and nuance of engagement within the rehabilitation context, which has implications for measuring engagement, training student clinicians to be skilled in engaging their clients and implementing person-centred practices that promote engagement within clinical settings. It is necessary to recognize that client and provider interactions (and thus engagement) are embedded in and influenced by the broader healthcare system. With this in mind, a patient-centred approach to engagement in aphasia care delivery cannot be achieved through individual efforts only and may require prioritization and action at the systems level. Future work is needed to explore barriers and facilitators to enacting engagement practices, in order to develop and test strategies to support practice change.

Communicative participation in goal-setting meetings for patients with aphasia after stroke. A study using patients' and healthcare professionals' self-ratings.

PURPOSE: Communicative participation poses a challenge in meetings between healthcare professionals (HCPs) and people with aphasia (PwA). How communication is affected by aphasia in group meetings, where several healthcare professionals participate together with the patient, is largely unexplored. The aim of this study was to investigate self-rated communicative participation during goal-setting meetings among PwA compared to patients without aphasia and to investigate whether communicative participation among PwA was associated with self-rated knowledge about aphasia among HCPs. A further aim was to investigate if there was a difference in the use of communication strategies among HCPs in the respective situations. METHODS: Nine PwA and nine control patients without aphasia rated their experience of communication during a goal-setting meeting. Thirty-eight HCPs rated their knowledge about aphasia and communication, and their use of communication strategies during goal-setting meetings. RESULTS: The PwA reported being listened to by the HCPs as well as being able to comprehend the meeting. PwA with more severe language impairment did not report a lower level of communicative participation compared to PwA with milder impairment. Half of the patients from both groups indicated some difficulty asking questions during the meeting. Patients' ratings of communication were not correlated to HCPs' knowledge of communication strategies. There was a significant difference in self-rated use of communication strategies among HCPs for the two conditions, although the individual variation was large. CONCLUSION: Results from both PwA and controls imply that patients may need more support to be able to ask questions in meetings with HCPs. Although self-ratings increase the ecological validity of the study of participation, further studies could benefit from using video observations in combination with self-reported experience, since awareness might influence results. WHAT THIS PAPER ADS: What is already known on this subject Aphasia is an acquired language disorder that affects patient-provider communication. In stroke rehabilitation, person-centred goal setting is a key component. If healthcare professionals (HCPs) are not able to use adequate communication strategies, a lack of accessible communication can become a barrier to person-centredness. There are evidence-based communication strategies which can be used to overcome this barrier. What this paper adds to existing knowledge This study aimed to investigate communicative participation during goal-setting meetings from the perspective of patients with aphasia and HCPs. To our knowledge, this is the first study where persons with aphasia are asked to rate communicative participation in goal-setting meetings. To broaden the perspective on communication and goal setting, ratings of patients with aphasia are compared to ratings by patients with stroke but no aphasia. The results of this study indicate that there is room for improvement regarding communication during goal-setting meetings. However, asking direct questions on communicative participation to persons with severe aphasia may not be feasible. What are the potential or actual clinical implications of this work? The results of this study imply that both patients with and without aphasia may need more support to be able to express themselves during goal-setting meetings. There also seems to be a need for further education on aphasia and communication strategies among rehabilitation professionals.

The longitudinal trajectory of discourse from the hyperacute to the chronic phase in mild to moderate poststroke aphasia recovery: A case series study.

BACKGROUND: Discourse analysis has recently received much attention in the aphasia literature. Even if post-stroke language recovery occurs throughout the longitudinal continuum of recovery, very few studies have documented discourse changes from the hyperacute to the chronic phases of recovery. AIMS: To document a multilevel analysis of discourse changes from the hyperacute phase to the chronic phase of post-stroke recovery using a series of single cases study designs. METHODS & PROCEDURES: Four people with mild to moderate post-stroke aphasia underwent four assessments (hyperacute: 0-24 h; acute: 24-72 h; subacute: 7-14 days; and chronic: 6-12 months post-onset). Three discourse tasks were performed at each time point: a picture description, a personal narrative and a story retelling. Multilevel changes in terms of macro- and microstructural aspects were analysed. The results of each discourse task were combined for each time point. Individual effect sizes were computed to evaluate the relative strength of changes in an early and a late recovery time frame. OUTCOMES & RESULTS: Macrostructural results revealed improvements throughout the recovery continuum in terms of coherence and thematic efficiency. Also, the microstructural results demonstrated linguistic output improvement for three out of four participants. Namely, lexical diversity and the number of correct information units/min showed a greater gain in the early compared with the late recovery phase. CONCLUSIONS & IMPLICATIONS: This study highlights the importance of investigating all discourse processing levels as the longitudinal changes in discourse operate differently at each phase of recovery. Overall results support future longitudinal discourse investigation in people with post-stroke aphasia. WHAT THIS PAPER ADDS: What is already known on the subject Multi-level discourse analysis allows for in-depth analysis of underlying discourse processes. To date, very little is known on the longitudinal discourse changes from aphasia onset through to the chronic stage of recovery. This study documents multi-level discourse features in four people with mild to moderate aphasia in the hyperacute, acute, subacute and chronic stage of post-stroke aphasia recovery. What this paper adds to existing knowledge The study found that most discourse variables demonstrated improvement throughout time. Macrostructural variables of coherence and thematic units improved throughout the continuum whereas microstructural variables demonstrated greater gains in the early compared to the late period of recovery. What are the potential or actual clinical implications of this work? This study suggests that multilevel discourse analysis will allow a better understanding of post-stroke aphasia recovery, although more research is needed to determine the clinical utility of these findings. Future research may wish to investigate longitudinal discourse recovery in a larger sample of people with aphasia with heterogenous aphasia profiles and severities.

Experiences of participating in group-based rehabilitation programmes: A qualitative study of community-dwelling adults with post-stroke aphasia.

BACKGROUND: People with post-stroke aphasia tend to have smaller social networks, a higher risk of depression and poorer health-related quality of life than those who do not have aphasia after stroke. Stroke-specific or general rehabilitation programmes offered by community-based organizations are commonly group-based and involve discussions among group members with or without stroke. Research has shown that people with post-stroke aphasia may be unable to participate fully in verbal sharing of experiences and exchange of thoughts. AIMS: To explore the experiences of people with post-stroke aphasia in relation to participating in group-based rehabilitation programmes organized by community-based organizations. METHODS & PROCEDURES: A qualitative design was adopted, including individual, semi-structured interviews with 20 adults with post-stroke aphasia recruited from community-based rehabilitation centres and support groups. The participants had a mean age of 68.86 ± 13.54 years and a mean post-stroke duration of 9.24 ± 7.72 years. They had participated in at least one group-based rehabilitation programme organized by community-based organizations in the past year. The participants were asked about their experiences of attending group-based programme(s), thoughts and feelings while interacting with the facilitators and group members, and satisfaction with their participation. The interview data were thematically analysed. OUTCOMES & RESULTS: Three themes were identified: (1) hurdles to active and fulfilling participation including the dominance of verbal sharing, short duration of the programme, being a minority in the group and accumulated negative experiences; (2) strategies adopted to improve participation including accepting a reduced speaking ability, having support from caregivers, and trying mobile apps to vocalize and supplement meanings; and (3) a preference for certain group conditions including receiving invitations by staff with whom they were familiar, groups that are led by experienced facilitators, a large or small group, the dominance of non-verbal activities, and inclusion of only people with post-stroke aphasia. CONCLUSIONS & IMPLICATIONS: The findings showed that people with post-stroke aphasia experience difficulties participating more actively in group-based rehabilitation programmes due to hurdles in terms of the structure and format of the programmes and accumulation of negative experiences. Facilitating positive group experiences for these people with innovative methods, such as using technology and providing professional and standby support, would be helpful. Longer sessions with smaller groups, exclusively including people with post-stroke aphasia and involving more non-verbal activities to help them express feelings, are suggested to optimize the benefits they derive from these group-based programmes. WHAT THIS PAPER ADDS: What is already known on the subject Stroke-specific or general group-based rehabilitation programmes are commonly offered by community-based organizations to support the recovery of people with or without stroke. However, some people with post-stroke aphasia may be unable to participate fully in verbal sharing of experiences and exchange of thoughts during these group-based programmes, which can limit the benefits they derive from these programmes. What this paper adds to existing knowledge This study explored the experiences of people with post-stroke aphasia in relation to participating in group-based rehabilitation programmes not specifically designed for people with stroke-induced aphasia organized by community-based organizations. The findings provide an insight into how these people participate in groups, their thoughts and feelings during interactions with the facilitators and group members, their satisfaction with their level of participation, and the characteristics of the groups they prefer to join. What are the potential or actual clinical implications of this work? People with post-stroke aphasia experience difficulties participating more actively in group-based programmes due to hurdles in terms of the structure and format of the group-based programmes and accumulation of negative experiences contributing to decreased motivation to participating in groups. More positive group experiences can be fostered by adopting longer sessions with smaller groups that exclusively include people with post-stroke aphasia and involve more non-verbal activities to help them express their feelings. Communication partner training for facilitators and the use of technology to support communication are suggested to promote active and fulfilling participation of the people with aphasia in group-based programmes.

Predicting home discharge after inpatient rehabilitation of stroke patients with aphasia.

The early identification of the discharge setting from Inpatient Rehabilitation Facilities is a primary goal in stroke-related research because of its clinical and socio-economic relevance. Several features have been identified as significant predictors of the discharge setting. Within cognitive deficits, aphasia is known to be a common and disabling condition that could influence rehabilitation outcome. However, it is often set as an exclusion criterion in stroke research. This study aims to investigate the predictive power of clinical variables, in particular specific language disturbances and nonlinguistic cognitive deficits, for discharge setting in post-acute stroke patients with aphasia after intensive multidisciplinary rehabilitation. In a sample of 158 patients, demographic, motor, language, and nonverbal cognitive data were retrospectively considered for the prediction of the discharge to home vs. another institutional setting. Univariate analysis identified relevant differences between groups and the significant variables were included in a logistic regression model. The results showed that better functional motor status, absence of dysphagia and unimpaired nonlinguistic cognitive profile independently predict the discharge to home. In particular, nonverbal cognitive functioning seemed to be specifically relevant within the aphasic population. The findings could be helpful for setting up the rehabilitation priorities and an adequate discharge arrangement.

A Comparative Investigation of Automatic Speech Recognition Platforms for Aphasia Assessment Batteries.

The rehabilitation of aphasics is fundamentally based on the assessment of speech impairment. Developing methods for assessing speech impairment automatically is important due to the growing number of stroke cases each year. Traditionally, aphasia is assessed manually using one of the well-known assessment batteries, such as the Western Aphasia Battery (WAB), the Chinese Rehabilitation Research Center Aphasia Examination (CRRCAE), and the Boston Diagnostic Aphasia Examination (BDAE). In aphasia testing, a speech-language pathologist (SLP) administers multiple subtests to assess people with aphasia (PWA). The traditional assessment is a resource-intensive process that requires the presence of an SLP. Thus, automating the assessment of aphasia is essential. This paper evaluated and compared custom machine learning (ML) speech recognition algorithms against off-the-shelf platforms using healthy and aphasic speech datasets on the naming and repetition subtests of the aphasia battery. Convolutional neural networks (CNN) and linear discriminant analysis (LDA) are the customized ML algorithms, while Microsoft Azure and Google speech recognition are off-the-shelf platforms. The results of this study demonstrated that CNN-based speech recognition algorithms outperform LDA and off-the-shelf platforms. The ResNet-50 architecture of CNN yielded an accuracy of 99.64 ± 0.26% on the healthy dataset. Even though Microsoft Azure was not trained on the same healthy dataset, it still generated comparable results to the LDA and superior results to Google's speech recognition platform.

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

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

Defining the Neurobiological Mechanisms of Action in Aphasia Therapies: Applying the Rehabilitation Treatment Specification System Framework to Research and Practice in Aphasia.

The Rehabilitation Treatment Specification System (RTSS) was developed as a systematic way to describe rehabilitation treatments for the purpose of both research and practice. The RTSS groups treatments by type and describes them by 3 elements: the treatment (1) ingredients and (2) the mechanisms of action that yield changes in the (3) target behavior. Adopting the RTSS has the potential to improve consistency in research, allowing for better cross-study comparisons to strengthen the body of research supporting various treatments. Because it is still early in its development, the RTSS has not yet been widely implemented across different rehabilitation disciplines. In particular, aphasia recovery is one area of rehabilitation that could benefit from a unifying framework. Accordingly, this article is part of a series where we illustrate how the RTSS can be applied to aphasia treatment and research. This article more specifically focuses on examining the neurobiological mechanisms of action associated with experimental aphasia therapies, including brain stimulation and pharmacologic intervention, as well as more traditional behavioral therapy. Key elements of the RTSS are described, and 4 example studies are used to illustrate how the RTSS can be implemented. The benefits of a unifying framework for the future of aphasia treatment research and practice are discussed.

Implementation Cost Analysis of an Intensive Comprehensive Aphasia Program.

OBJECTIVE: To identify and measure the costs of implementing an intensive comprehensive aphasia program (ICAP). DESIGN: Retrospective cost analysis of a clinical ICAP. Cost inputs were gathered directly from the provider of the ICAP. We performed several sensitivity analyses to examine major cost drivers and to separate start-up costs from operating costs. SETTING: Urban rehabilitation hospital. PARTICIPANTS: Adults with aphasia. MAIN OUTCOME MEASURES: Total implementation cost to the provider. RESULTS: Implementation cost of running the ICAP for the first time was $133,644 for a cohort of 8 participants with aphasia. Break-even charges per participant ranged from $15,278 for 10 participants to $19,700 for 6 participants. After accounting for start-up costs and efficiencies gained, the fourth and subsequent programs were estimated to cost $84,855 each. The majority of the costs were personnel costs, and the cost of the speech language pathologist's time was the main cost driver in this analysis. CONCLUSIONS: Initial implementation costs are high compared with subsequent programs. Future work should examine effectiveness of an ICAP compared with other treatments to determine its cost-effectiveness.

Demystifying the Complexity of Aphasia Treatment: Application of the Rehabilitation Treatment Specification Systemx.

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