Applying the Rehabilitation Treatment Specification System to Functional Communication Treatment Approaches for Aphasia.

There are many different approaches to the rehabilitation of patients with aphasia, a communication disorder that affects a person's understanding and expression of spoken and written language. One approach called "functional communication interventions" aims to enhance communication success as opposed to solely improving linguistic abilities. This approach encompasses many skills (eg, gesturing) and factors (eg, access to communication supports) that support sending and receiving messages in "real-world" daily activities and environments. Functional communication treatments are highly diverse and not always well described. A framework that may provide structure to the description of functional communication interventions for aphasia is the Rehabilitation Treatment Specification System (RTSS). The RTSS was developed by an interdisciplinary research team to describe interventions across any rehabilitation discipline and in any setting or format. The RTSS uses a common language and a systematic approach to describing treatment and includes 3 connected elements-a single target, 1 or more ingredients, and a mechanism of action-that, taken together, attempt to explain how and why a treatment works. Although the RTTS has been described previously within the field of speech-language pathology, it has not yet been applied to the field of aphasiology. We applied the RTSS framework to a sample of peer-reviewed studies that represent functional communication treatments, including Promoting Aphasics' Communicative Effectiveness (PACE), modified Response Elaboration Training (M-RET), script training, conversation treatment, and communication partner training. We discuss both the advantages and disadvantages of using the RTSS framework to better understand the important elements of functional communication treatment approaches for aphasia.

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.

Effects of animacy and sentence type on silent reading comprehension in aphasia: An eye-tracking study.

The present study examined how healthy aging and aphasia influence the capacity for readers to generate structural predictions during online reading, and how animacy cues influence this process. Non-brain-damaged younger (n =24) and older (n =12) adults (Experiment 1) and individuals with aphasia (IWA; n =11; Experiment 2) read subject relative and object relative sentences in an eye-tracking experiment. Half of the sentences included animate sentential subjects, and the other half included inanimate sentential subjects. All three groups used animacy information to mitigate effects of syntactic complexity. These effects were greater in older than younger adults. IWA were sensitive to structural frequency, with longer reading times for object relative than subject relative sentences. As in previous work, effects of structural complexity did not emerge on IWA's first pass through the sentence, but were observed when IWA reread critical segments of the sentences. Thus, IWA may adopt atypical reading strategies when they encounter low frequency or complex sentence structures, but they are able to use animacy information to reduce the processing disruptions associated with these structures.

Efficacy of Group Conversation Intervention in Individuals with Severe Profiles of Aphasia.

An estimated 390,000 to 520,000 individuals with severe aphasia (IWSA) currently live in the United States. IWSA experience profound social isolation, which is associated with a wide range of negative health outcomes, including mortality. Treatments for severe aphasia frequently focus on compensatory communication approaches or a discrete communication act rather than on participation-based treatment. The purpose of this study was to determine whether IWSA demonstrated improved performance on standardized language measures, patient-reported outcome measures, and connected speech samples as a result of client-centered conversation group treatment. Results of assessments conducted at pretreatment, posttreatment, and maintenance intervals were variable across participants. All participants demonstrated improvement in at least one of the outcome measures considered. Importantly, none of these measures fully captured how IWSA were able to convey their thoughts in supported conversation. The results lend support for the use of conversation treatment for, and for further study in, this subpopulation of individuals with aphasia.

Sentence comprehension in older adults: evidence for risky processing strategies.

UNLABELLED: BACKGROUND/STUDY CONTEXT: Previous research has suggested that older adults compensate for age-related declines in sentence comprehension ability by reading more slowly. The purpose of this study was to investigate the hypothesis that older adults adopt a riskier strategy than younger adults, in which they rely on expectations based on probabilistic cues. METHODS: Older and younger adults read late closure sentences in a self-paced reading task (e.g., "When the waiter served the woman the food was still too hot."). The subordinate verbs varied in whether or not they occurred in ditransitive constructions (served vs. kissed). RESULTS: Older adults showed less evidence of processing disruptions at the ambiguous noun phrase (the food) than younger adults. At the main verb, the older and younger adults showed evidence of processing disruption in the same conditions, but the processing disruptions were greater in older adults. CONCLUSION: The results are interpreted as support for the hypothesis that older adults adopt "risky" strategies during sentence comprehension.

Effects of linguistic context and noise type on speech comprehension.

Introduction: Understanding speech in background noise is an effortful endeavor. When acoustic challenges arise, linguistic context may help us fill in perceptual gaps. However, more knowledge is needed regarding how different types of background noise affect our ability to construct meaning from perceptually complex speech input. Additionally, there is limited evidence regarding whether perceptual complexity (e.g., informational masking) and linguistic complexity (e.g., occurrence of contextually incongruous words) interact during processing of speech material that is longer and more complex than a single sentence. Our first research objective was to determine whether comprehension of spoken sentence pairs is impacted by the informational masking from a speech masker. Our second objective was to identify whether there is an interaction between perceptual and linguistic complexity during speech processing. Methods: We used multiple measures including comprehension accuracy, reaction time, and processing effort (as indicated by task-evoked pupil response), making comparisons across three different levels of linguistic complexity in two different noise conditions. Context conditions varied by final word, with each sentence pair ending with an expected exemplar (EE), within-category violation (WV), or between-category violation (BV). Forty young adults with typical hearing performed a speech comprehension in noise task over three visits. Each participant heard sentence pairs presented in either multi-talker babble or spectrally shaped steady-state noise (SSN), with the same noise condition across all three visits. Results: We observed an effect of context but not noise on accuracy. Further, we observed an interaction of noise and context in peak pupil dilation data. Specifically, the context effect was modulated by noise type: context facilitated processing only in the more perceptually complex babble noise condition. Discussion: These findings suggest that when perceptual complexity arises, listeners make use of the linguistic context to facilitate comprehension of speech obscured by background noise. Our results extend existing accounts of speech processing in noise by demonstrating how perceptual and linguistic complexity affect our ability to engage in higher-level processes, such as construction of meaning from speech segments that are longer than a single sentence.

Interplay of Semantic Plausibility and Word Order Canonicity in Sentence Processing of People With Aphasia Using a Verb-Final Language.

PURPOSE: The Western Aphasia Battery is widely used to assess people with aphasia (PWA). Sequential Commands (SC) is one of the most challenging subtests for PWA. However, test items confound linguistic factors that make sentences difficult for PWA. The current study systematically manipulated semantic plausibility and word order in sentences like those in SC to examine how these factors affect comprehension deficits in aphasia. METHOD: Fifty Korean speakers (25 PWA and 25 controls) completed a sentence-picture matching task that manipulated word order (canonical vs. noncanonical) and semantic plausibility (plausible vs. less plausible). Analyses focused on accuracy and aimed to identify sentence types that best discriminate the groups. Additionally, we explored which sentence type serves as the best predictor of aphasia severity. RESULTS: PWA demonstrated greater difficulties in processing less plausible sentences than plausible ones compared to the controls. Across the groups, noncanonical and less plausible sentences elicited lower accuracy than canonical and plausible sentences. Notably, the accuracy of PWA and control groups differed in noncanonical and less plausible sentences. Additionally, aphasia severity significantly correlated with less plausible sentences. CONCLUSION: Even in languages with flexible word order, PWA find it challenging to process sentences with noncanonical syntactic structures and less plausible semantic roles.

Efficacy of Aphasia Group Conversation Treatment via Telepractice on Language and Patient-Reported Outcome Measures.

PURPOSE: Conversation treatment for people with aphasia (PwA) can lead to significant changes in language impairment and quality of life. The COVID-19 pandemic has resulted in the greater use of telepractice treatment delivery. However, there is little evidence regarding the efficacy of telepractice conversation groups. This study investigated the effects of telepractice group conversation treatment on standardized measures of language function and socially oriented/patient-reported outcomes compared to in-person and no-treatment control data. METHOD: This study used a mixed within- and between-groups design (repeated measure/pre-post treatment), with a single-subject delayed treatment design (Shadish & Rindskopf, 2007) to establish baseline, pretreatment, and posttreatment periods for the telepractice group. Telepractice results pre- and posttreatment were compared with historical in-person and no-treatment control data obtained from a larger randomized control trial (RCT) from DeDe et al. (2019). The historical comparison data were a subset of RCT participants from the same location and included six in-person participants and seven no-treatment control group participants. RESULTS: Results of standardized testing conducted at baseline, pretreatment, and posttreatment intervals revealed significant improvement from pre- to posttreatment on repetition and picture description tasks for the telepractice group, and significant improvement from pre- to posttreatment on the Aphasia Communication Outcome Measure, total number of relevant utterances, and percentage of complete utterances for the in-person conversation group. No significant differences were observed in the no-treatment groups. CONCLUSIONS: In contrast to the no-treatment condition, both the in-person and telepractice conditions showed the benefits of conversation group treatment. The in-person treatment condition showed improvements in a wider number of outcome measures than the telepractice condition. Overall, the results prompt further research regarding telepractice group conversation treatment for PwA.

Lexical and prosodic effects on syntactic ambiguity resolution in aphasia.

The purpose of this study was to determine whether and when individuals with aphasia and healthy controls use lexical and prosodic information during on-line sentence comprehension. Individuals with aphasia and controls (n = 12 per group) participated in a self-paced listening experiment. The stimuli were early closure sentences, such as "While the parents watched(,) the child sang a song." Both lexical and prosodic cues were manipulated. The cues were biased toward the subject- or object- of the ambiguous noun phrase (the child). Thus, there were two congruous conditions (in which both lexical cues and prosodic cues were consistent) and two incongruous conditions (in which lexical and prosodic cues conflicted). The results showed that the people with aphasia had longer listening times for the ambiguous noun phrase (the child) when the cues were conflicting, rather than consistent. The controls showed effects earlier in the sentence, at the subordinate verb (watched or danced). Both groups showed evidence of reanalysis at the main verb (sang). These effects demonstrate that the aphasic group was sensitive to the lexical and prosodic cues, but used them on a delayed time course relative to the control group.

Sentence Production in a Discourse Context in Latent Aphasia: A Real-Time Study.

PURPOSE: The purpose of this study was to improve our understanding as to which factors determine online, spoken sentence production abilities of adults with latent aphasia in a discourse context. METHOD: Discourse samples of the story of Cinderella elicited from AphasiaBank were analyzed with speech analysis software. Participants comprised people with latent and anomic aphasia as well as neurotypical controls (10 per group). Durations of pauses (silent and filled) were analyzed according to (a) the location they occurred (between or within sentences), (b) the syntactic complexity of sentences (simple, complex), and (c) sentence length (number of words). Statistical comparisons were conducted using mixed-effect models. RESULTS: The two clinical groups (latent and anomic) differed from controls in the duration of pauses, both between and within sentences. Syntactic complexity did not exert an effect on either of the two clinical groups as compared with controls. As compared with controls, both clinical groups paused more before long in comparison with short sentences. CONCLUSION: Reduction in processing speed, which affects the ability to simultaneously maintain multiple linguistic and other cognitive demands associated with planning and monitoring of utterances, is a major factor that compromises sentence production in spoken discourse in latent aphasia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19448726.

A Randomized Controlled Trial of the Effects of Group Conversation Treatment on Monologic Discourse in Aphasia.

PURPOSE: Evidence has shown that group conversation treatment may improve communication and reduce social isolation for people with aphasia. However, little is known about the impact of conversation group treatment on measures of discourse. This project explored the impact of conversation treatment on measures of monologic discourse. METHOD: In this randomized controlled trial, 48 participants with chronic aphasia were randomly assigned to dyadic, large group, or control conditions. Conversation group treatment was provided for 1 hr, twice per week, for 10 weeks. Discourse samples were collected and coded at pretreatment, posttreatment, and 6-week maintenance. There were three narrative tasks: (a) Comprehensive Aphasia Test (CAT) picture description, (b) Cat Rescue Picture, and (c) Cinderella retell. All narratives were coded using the percent correct information units (percent CIUs), the CAT standardized narrative analysis method, and the complete utterance (CU) method. RESULTS: No significant changes were observed on percent CIU, which was the primary outcome measure. The treated groups demonstrated improvement on aspects of the CU method following treatment, whereas the control group did not. Significant changes were observed for other CIU measures and the CAT standardized narrative analysis in both the treated and control groups. CONCLUSIONS: The results suggest that the CU measures were more sensitive to the effects of conversation treatment in monologic discourse compared to CIU and CAT measures. Changes were more common in absolute rather than relative values, suggesting that conversation treatment impacts the overall amount of language produced rather than efficiency of production.

Rasch models of aphasic performance on syntactic comprehension tests.

Responses of 42 people with aphasia to 11 sentence types in enactment and sentence-picture matching tasks were characterized using Rasch models that varied in the inclusion of the factors of task, sentence type, and patient group. The best fitting models required the factors of task and patient group but not sentence type. The results provide evidence that aphasic syntactic comprehension is best accounted for by models that include different estimates of patient ability in different tasks and different difficulty of all sentences in different groups of patients, but that do not include different estimates of patient ability for different types of sentences.

Utilization of prosodic information in syntactic ambiguity resolution.

Two self paced listening experiments examined the role of prosodic phrasing in syntactic ambiguity resolution. In Experiment 1, the stimuli consisted of early closure sentences (e.g., "While the parents watched, the child sang a song.") containing transitive-biased subordinate verbs paired with plausible direct objects or intransitive-biased subordinate verbs paired with implausible direct objects. Experiment 2 also contained early closure sentences with transitively and intransitive-biased subordinate verbs, but the subordinate verbs were always followed by plausible direct objects. In both experiments, there were two prosodic conditions. In the subject-biased prosodic condition, an intonational phrase boundary marked the clausal boundary following the subordinate verb. In the object-biased prosodic condition, the clause boundary was unmarked. The results indicate that lexical and prosodic cues interact at the subordinate verb and plausibility further affects processing at the ambiguous noun. Results are discussed with respect to models of the role of prosody in sentence comprehension.

Perceptual span in individuals with aphasia.

BACKGROUND: Perceptual span refers to the field of effective vision during reading comprehension. It is determined by many factors, including reading proficiency. No studies have investigated the perceptual span in people with reading comprehension impairments due to aphasia. AIMS: The present study examined whether perceptual span is smaller in individuals with aphasia than controls. METHODS AND PROCEDURES: The task was a gaze-contingent moving windows paradigm during silent reading using an eye tracker. Data from 11 individuals with aphasia and 15 neurotypical controls were analyzed. OUTCOMES AND RESULTS: Perceptual span in individuals with aphasia was the fixated word plus one word to the right of fixation, whereas perceptual span in controls was the fixated word plus two words to the right of fixation. CONCLUSION: Individuals with aphasia have a smaller perceptual span than controls, which likely reflects increased effort during reading comprehension.

Temporal and Episodic Analyses of the Story of Cinderella in Latent Aphasia.

Purpose The purpose of this study was to improve our understanding of the language characteristics of people with latent aphasia using measures that examined temporal (i.e., real-time) and episodic organization of discourse production. Method Thirty AphasiaBank participants were included (10 people with latent aphasia, 10 people with anomic aphasia, and 10 neurotypical control participants). Speech material of Cinderella narratives was analyzed with Praat software. We devised a protocol that coded the presence and duration of all speech segments, dysfluencies such as silent and filled pauses, and other speech behaviors. Using these durations, we generated a range of temporal measures such as speech, articulation, and pure word rates. Narratives were also coded into episodes, which provided information about the discourse macrostructure abilities of the participants. Results The latent aphasia group differed from controls in number of words produced, silent pause duration, and speech rate, but not articulation rate or pure word rate. Episodic organization of the narratives was similar in these 2 groups. The latent and anomic aphasia groups were similar in most measures, apart from articulation rate, which was lower in the anomic group. The anomic aphasia group also omitted more episodes than the latent aphasia group. Conclusions The differences between latent aphasia and neurotypical controls can be attributed to a processing speed deficit. We propose that this deficit results in an impaired ability to process information from multiple cognitive domains simultaneously.

What Drives Task Performance During Animal Fluency in People With Alzheimer's Disease?

BACKGROUND: Animal fluency is a widely used task to assess people with Alzheimer's disease (AD) and other neurological disorders. The mechanisms that drive performance in this task are argued to rely on language and executive functions. However, there is little information regarding what specific aspects of these cognitive processes drive performance on this task. OBJECTIVE: To understand which aspects of language (i.e., semantics, phonological output lexicon, phonological assembly) and executive function (i.e., mental set shifting; information updating and monitoring; inhibition of possible responses) are involved in the performance of animal fluency in people with AD. METHODS: Animal fluency data from 58 people with probable AD from the DementiaBank Pittsburgh Corpus were analyzed. Number of clusters and switches were measured and nine word properties (e.g., frequency, familiarity) for each of the correct words (i.e., each word counting toward the total score, disregarding non-animals and repetitions) were determined. Random forests were used to understand which variables predicted the total number of correct words, and conditional inference trees were used to search for interactions between the variables. Finally, Wilcoxon tests were implemented to cross-validate the results, by comparing the performance of participants with scores below the norm in animal fluency against participants with scores within the norm based on a large normative sample. RESULTS: Switches and age of acquisition emerged as the most important variables to predict total number of correct words in animal fluency in people with AD. Cross-validating the results, people with AD whose animal fluency scores fell below the norm produced fewer switches and words with lower age of acquisition than people with AD with scores in the normal range. CONCLUSION: The results indicate that people with AD rely on executive functioning (information updating and monitoring) and language (phonological output lexicon, not necessarily semantics) to produce words on animal fluency.

Two to Tango or the More the Merrier? A Randomized Controlled Trial of the Effects of Group Size in Aphasia Conversation Treatment on Standardized Tests.

Purpose Group conversation treatment has the potential to improve communication and reduce social isolation for people with aphasia. This project examined how 2 conflicting hypotheses-treatment dosage and group dynamics-affect treatment outcomes. Method Forty-eight participants with chronic aphasia were randomly assigned to either a dyad, a large group, or a delayed control group. Conversation group treatment was provided for an hour, twice per week, for 10 weeks. Individual goals were developed by each participant and addressed in the context of thematically oriented conversation treatment. Standardized testing across language domains was completed pretreatment (Time 1), posttreatment (Time 2), at a 6-week maintenance point (Time 3), and at 11-month follow-up for the experimental groups. Results Treatment groups showed greater changes on standardized measures than the control group posttreatment. Dyads showed the most changes on measures of language impairment, whereas changes on the self-reported functional communication measure (Aphasia Communication Outcome Measure) and connected speech task only showed significant changes in the large group. Conclusions This randomized controlled trial on conversation treatment indicated that both treatment groups-but not the delayed control group-showed significant changes on standardized tests. Hence, conversation treatment is associated with changes in measures of language impairment and quality of life. Dyads showed the most changes on measures of language impairment, whereas changes on the functional communication measure (Aphasia Communication Outcome Measure) and discourse production only showed significant changes in the large group. Thus, group size may be associated with effects on different types of outcome measures.

A study of syntactic processing in aphasia I: behavioral (psycholinguistic) aspects.

This paper presents the results of a study of syntactically based comprehension in aphasic patients. We studied 42 patients with aphasia secondary to left hemisphere strokes and 25 control participants. We measured off-line, end-of-sentence, performance (accuracy and reaction time) in two tasks that require comprehension--enactment and sentence-picture matching--and in grammaticality judgment, with whole sentence auditory presentation. We also used sentence-picture matching and grammaticality judgment as tasks in two self-paced listening studies with the same patients to measure on-line performance. In each task and presentation format, we presented sentences that tested the ability to assign and interpret three structural contrasts chosen to examine different basic syntactic operations: actives and passives, subject and object extracted relative clauses, and reflexive pronouns and matched sentences without these elements. We examined these behavioral data to determine patterns of impairment in individual patients and in groups of patients, using correlational analyses, factor analyses, and analyses of variance. The results showed that almost no individual patients had stable deficits referable to the ability to interpret individual syntactic structures, that a variety of structural features contributed to sentence processing complexity both on-line and off-line, that correct responses were associated with normal on-line and errors with abnormal performance, and that the major determinant of performance is a factor that affected performance on all sentence types. The results indicate that the major cause of aphasic impairments of syntactically based comprehension are intermittent reductions in the processing capacity available for syntactic, interpretive, and task-related operations.

A study of syntactic processing in aphasia II: neurological aspects.

This paper presents the results of a study of the effects of left hemisphere strokes on syntactically-based comprehension in aphasic patients. We studied 42 patients with aphasia secondary to left hemisphere strokes and 25 control subjects for the ability to assign and interpret three syntactic structures (passives, object extracted relative clauses, and reflexive pronouns) in enactment, sentence-picture matching and grammaticality judgment tasks. We measured accuracy, RT and self-paced listening times in SPM and GJ. We obtained magnetic resonance (MR) and 5-deoxyglucose positron emission tomography (FDG PET) data on 31 patients and 12 controls. The percent of selected regions of interest (ROIs) that was lesioned on MR and the mean normalized PET counts per voxel in ROIs were calculated. In regression analyses, lesion measures in both perisylvian and non-perisylvian ROIs predicted performance. Patients who performed at similar levels behaviorally had lesions of very different sizes, and patients with equivalent lesion sizes varied greatly in their level of performance. The data are consistent with a model in which the neural tissue that is responsible for the operations underlying sentence comprehension and syntactic processing is localized in different neural regions in different individuals.

Effects of Lexical Variables on Silent Reading Comprehension in Individuals With Aphasia: Evidence From Eye Tracking.

Purpose: Previous eye-tracking research has suggested that individuals with aphasia (IWA) do not assign syntactic structure on their first pass through a sentence during silent reading comprehension. The purpose of the present study was to investigate the time course with which lexical variables affect silent reading comprehension in IWA. Three lexical variables were investigated: word frequency, word class, and word length. Methods: IWA and control participants without brain damage participated in the experiment. Participants read sentences while a camera tracked their eye movements. Results: IWA showed effects of word class, word length, and word frequency that were similar to or greater than those observed in controls. Conclusions: IWA showed sensitivity to lexical variables on the first pass through the sentence. The results are consistent with the view that IWA focus on lexical access on their first pass through a sentence and then work to build syntactic structure on subsequent passes. In addition, IWA showed very long rereading times and low skipping rates overall, which may contribute to some of the group differences in reading comprehension.