Articulation Rate, Pauses, and Disfluencies in Professional Fighters: Potential Speech Biomarkers for Repetitive Head Injury.

OBJECTIVE: As part of a larger study dedicated to identifying speech and language biomarkers of neurological decline associated with repetitive head injury (RHI) in professional boxers and mixed martial artists (MMAs), we examined articulation rate, pausing, and disfluency in passages read aloud by participants in the Professional Athletes Brain Health Study. SETTING: A large outpatient medical center specializing in neurological care. PARTICIPANTS, DESIGN, AND MAIN MEASURES: Passages read aloud by 60 boxers, 40 MMAs, and 55 controls were acoustically analyzed to determine articulation rate (the number of syllables produced per second), number and duration of pauses, and number and duration of disfluencies in this observational study. RESULTS: Both boxers and MMAs differed from controls in articulation rate, producing syllables at a slower rate than controls by nearly half a syllable per second on average. Boxers produced significantly more pauses and disfluencies in passages read aloud than MMAs and controls. CONCLUSIONS: Slower articulation rate in both boxers and MMA fighters compared with individuals with no history of RHI and the increased occurrence of pauses and disfluencies in the speech of boxers suggest changes in speech motor behavior that may relate to RHI. These speech characteristics can be measured in everyday speaking conditions and by automatic recognition systems, so they have the potential to serve as effective, noninvasive clinical indicators for RHI-associated neurological decline.

Moving Toward Non-transcription based Discourse Analysis in Stable and Progressive Aphasia.

Measurement of communication ability at the discourse level holds promise for predicting how well persons with stable (e.g., stroke-induced), or progressive aphasia navigate everyday communicative interactions. However, barriers to the clinical utilization of discourse measures have persisted. Recent advancements in the standardization of elicitation protocols and the existence of large databases for development of normative references have begun to address some of these barriers. Still, time remains a consistently reported barrier by clinicians. Non-transcription based discourse measurement would reduce the time required for discourse analysis, making clinical utilization a reality. The purpose of this article is to present evidence regarding discourse measures (main concept analysis, core lexicon, and derived efficiency scores) that are well suited to non-transcription based analysis. Combined with previous research, our results suggest that these measures are sensitive to changes following stroke or neurodegenerative disease. Given the evidence, further research specifically assessing the reliability of these measures in clinical implementation is warranted.

A Compendium of Core Lexicon Checklists.

Core Lexicon (CoreLex) is a relatively new approach assessing lexical use in discourse. CoreLex examines the specific lexical items used to tell a story, or how typical lexical items are compared with a normative sample. This method has great potential for clinical utilization because CoreLex measures are fast, easy to administer, and correlate with microlinguistic and macrolinguistic discourse measures. The purpose of this article is to provide clinicians with a centralized resource for currently available CoreLex checklists, including information regarding development, norms, and guidelines for use.

Can Script Training Improve Narrative and Conversation in Aphasia across Etiology?

Script training is an effective treatment of stable (e.g., stroke-induced) and progressive aphasia of varying severities and subtypes. The theoretical underpinnings of script training are discussed and include fluency-inducing conditions, speech shadowing, principles of neuroplasticity, and automatization. Script training outcomes are reviewed, with a focus on discourse in persons with stable aphasia (PWSAs) and in persons with primary progressive aphasia (PWPPAs). PWSAs and PWPPAs are able to acquire and maintain short scripted monologues or conversational dialogues, with some evidence of generalization to untrained topics and settings. Advances in both technology and access have enriched script training protocols, so they now range from no-tech written script approaches to high-tech audiovisual support and avatars. Advances in audio and/or visual support promote large amounts of practice of less errorful whole-message language processing during a fluent language inducing condition. With enough practice, users decrease reliance on supports and independently produce scripted content. Script training can be delivered in a variety of settings (individual, group, telepractice), lends itself well to homework programs, and is in accordance with the principles of neuroplasticity for neurorehabilitation. Incorporating script training into therapy programming is advantageous throughout aphasia recovery following brain injuries such as stroke. It is also beneficial for persons with progressive disease for prophylaxis, remediation, and compensation. Recommendations for implementing script training in clinical practice and future research directions are presented.

Cortical disconnection of the ipsilesional primary motor cortex is associated with gait speed and upper extremity motor impairment in chronic left hemispheric stroke.

Advances in neuroimaging have enabled the mapping of white matter connections across the entire brain, allowing for a more thorough examination of the extent of white matter disconnection after stroke. To assess how cortical disconnection contributes to motor impairments, we examined the relationship between structural brain connectivity and upper and lower extremity motor function in individuals with chronic stroke. Forty-three participants [mean age: 59.7 (±11.2) years; time poststroke: 64.4 (±58.8) months] underwent clinical motor assessments and MRI scanning. Nonparametric correlation analyses were performed to examine the relationship between structural connectivity amid a subsection of the motor network and upper/lower extremity motor function. Standard multiple linear regression analyses were performed to examine the relationship between cortical necrosis and disconnection of three main cortical areas of motor control [primary motor cortex (M1), premotor cortex (PMC), and supplementary motor area (SMA)] and motor function. Anatomical connectivity between ipsilesional M1/SMA and the (1) cerebral peduncle, (2) thalamus, and (3) red nucleus were significantly correlated with upper and lower extremity motor performance (P ≤ 0.003). M1-M1 interhemispheric connectivity was also significantly correlated with gross manual dexterity of the affected upper extremity (P = 0.001). Regression models with M1 lesion load and M1 disconnection (adjusted for time poststroke) explained a significant amount of variance in upper extremity motor performance (R2  = 0.36-0.46) and gait speed (R2  = 0.46), with M1 disconnection an independent predictor of motor performance. Cortical disconnection, especially of ipsilesional M1, could significantly contribute to variability seen in locomotor and upper extremity motor function and recovery in chronic stroke. Hum Brain Mapp 39:120-132, 2018. © 2017 Wiley Periodicals, Inc.

Verb Argument Structure in Narrative Speech: Mining AphasiaBank.

Previous research has found that verb argument structure characteristics (such as the number of participant roles in the situation described by the verb) can facilitate or hinder aphasic language production and comprehension in constrained laboratory tasks. This research needs to be complemented by studies of narrative or unrestricted speech, which can capture the spontaneous selection of verbs and grammatical structures by people with aphasia and may be particularly sensitive to the relative cost of access to different verb types in more natural conditions. Focusing on the number of subcategorization options, we investigated verb argument structure effects in a large sample of narratives from AphasiaBank, by speakers with aphasia, as well as control speakers without brain damage. Verb argument structure complexity did not negatively affect verb selection in any type of aphasia. However, people with aphasia, particularly with Broca's aphasia, used verbs in less complex and diverse ways, with fewer arguments and less diverse subcategorization options. In line with previous research, this suggests that deficits in verb use in aphasia are likely due to difficulties with the online application of or partial damage to verb argument structure knowledge.

Targeted transcranial direct current stimulation for rehabilitation after stroke.

Transcranial direct current stimulation (tDCS) is being investigated as an adjunctive technique to behavioral rehabilitation treatment after stroke. The conventional "dosage", consisting of a large (25 cm(2)) anode over the target with the cathode over the contralateral hemisphere, has been previously shown to yield broadly distributed electric fields whose intensities at the target region are less than maximal. Here, we report the results of a systematic targeting procedure with small "high-definition" electrodes that was used in preparation for a pilot study on 8 stroke patients with chronic aphasia. We employ functional and anatomical magnetic resonance imagery (fMRI/MRI) to define a target and optimize (with respect to the electric field magnitude at the target) the electrode configuration, respectively, and demonstrate that electric field strengths in targeted cortex can be substantially increased (63%) over the conventional approach. The optimal montage exhibits significant variation across subjects as well as when perturbing the target location within a subject. However, for each displacement of the target co-ordinates, the algorithm is able to determine a montage which delivers a consistent amount of current to that location. These results demonstrate that MRI-based models of current flow yield maximal stimulation of target structures, and as such, may aid in reliably assessing the efficacy of tDCS in neuro-rehabilitation.

Do People With Apraxia of Speech and Aphasia Improve or Worsen Across Repeated Sequential Word Trials?

PURPOSE: During motor speech examinations for suspected apraxia of speech (AOS), clients are routinely asked to repeat words several times sequentially. The purpose of this study was to understand the task in terms of the relationship among consecutive attempts. We asked to what extent phonemic accuracy changes across trials and whether the change is predicted by AOS diagnosis and sound production severity. METHOD: One hundred thirty-three participants were assigned to four diagnostic groups based on quantitative metrics (aphasia plus AOS, aphasia-only, and aphasia with two borderline speech profiles). Each participant produced four multisyllabic words 5 times consecutively. These productions were audio-recorded and transcribed phonetically and then summarized as the proportion of target phonemes that was produced accurately. Nonparametric statistics were used to analyze percent change in accuracy from the first to the last production based on diagnostic group and a broad measure of speech sound accuracy. RESULTS: Accuracy on the repeated words deteriorated across trials for all groups, showing reduced accuracy from the first to the last repetition for 62% of participants. Although diagnostic groups differed on the broad measure of speech sound accuracy, severity classification based on this measure did not determine degree of deterioration on the repeated words task. DISCUSSION: Responding to a request to say multisyllabic words 5 times sequentially is challenging for people with aphasia with and without AOS, and as such, performance is prone to errors even with mild impairment. For most, the task does not encourage self-correction. Instead, it promotes errors, regardless of diagnosis, and is, therefore, useful for screening purposes.

Left hemisphere plasticity and aphasia recovery.

A recent study by our group revealed a strong relationship between functional brain changes in the left hemisphere and anomia treatment outcome in chronic stroke patients (N=26) with aphasia (Fridriksson, 2010). The current research represents a continuation of this work in which we have refined our methods and added data from four more patients (for a total sample size of 30) to assess where in the left hemisphere treatment-related brain changes occur. Unlike Fridriksson (2010) which only focused on changes in correct naming as a marker of treatment outcome, the current study examined the relationship between changes in left hemisphere activity and changes in correct naming, semantic paraphasias, and phonemic paraphasias following treatment. We also expanded on the work by Fridriksson by examining whether neurophysiological measures taken at baseline (defined henceforth as the time-point before the start of anomia treatment) predict treatment outcome. Our analyses revealed that changes in activation in perilesional areas predicted treatment-related increases in correct naming in individuals with chronic aphasia. This relationship was most easily observed in the left frontal lobe. A decrease in the number of semantic and phonemic paraphasias was predicted by an activation change in the temporal lobe involving cortical areas that were shown to be active during picture naming in 14 normal subjects. In contrast, a far less certain relationship was found between baseline neurophysiological measures and anomia treatment outcome. Our findings suggest that improved naming associated with behavioral anomia treatment in aphasia is associated with modulation of the left frontal lobe whereas a reduction in naming errors is mediated by left posterior regions that classically are thought to be involved in language processing.

Assessment of language impairment and function.

This chapter is written for the qualified neurologist or related professional working with persons who have had a stroke or other sudden brain injury. It is critical that the presence of aphasia is detected, no matter how mild the presentation, and to support that assertion, this chapter highlights the plight of persons with latent aphasia. At the individual level, the impact of aphasia is devastating, with overwhelming evidence that aphasia negatively impacts psychosocial outcomes. At the global level, sensitive detection and accurate diagnosis of aphasia are critical for accurate characterization and quantification of the global burden of aphasia. The word "LANGUAGE" is leveraged as an acronym to create a useful and memorable checklist to guide navigation of aphasia screening and assessment: it begins with the definition of language (L), followed by the definition and diagnostic criteria for aphasia (A). Then language abilities and characteristics to be considered in assessment are presented: naming (N); grammar and syntax (G); unintelligible words, jargon, and paraphasias (U); auditory comprehension and repetition (A); graphemic abilities-reading and writing (G); and everyday communication and discourse (E). Recommendations for improving procedural adherence are provided, and a list of potential brief assessment measures are introduced.

Transcranial direct current stimulation modulates working memory and prefrontal-insula connectivity after mild-moderate traumatic brain injury.

Background: Persistent posttraumatic symptoms (PPS) may manifest after a mild-moderate traumatic brain injury (mmTBI) even when standard brain imaging appears normal. Transcranial direct current stimulation (tDCS) represents a promising treatment that may ameliorate pathophysiological processes contributing to PPS. Objective/Hypothesis: We hypothesized that in a mmTBI population, active tDCS combined with training would result in greater improvement in executive functions and post-TBI cognitive symptoms and increased resting state connectivity of the stimulated region, i.e., left dorsolateral prefrontal cortex (DLPFC) compared to control tDCS. Methods: Thirty-four subjects with mmTBI underwent baseline assessments of demographics, symptoms, and cognitive function as well as resting state functional magnetic resonance imaging (rsfMRI) in a subset of patients (n = 24). Primary outcome measures included NIH EXAMINER composite scores, and the Neurobehavioral Symptom Inventory (NSI). All participants received 10 daily sessions of 30 min of executive function training coupled with active or control tDCS (2 mA, anode F3, cathode right deltoid). Imaging and assessments were re-obtained after the final training session, and assessments were repeated after 1 month. Mixed-models linear regression and repeated measures analyses of variance were calculated for main effects and interactions. Results: Both active and control groups demonstrated improvements in executive function (EXAMINER composite: p < 0.001) and posttraumatic symptoms (NSI cognitive: p = 0.01) from baseline to 1 month. Active anodal tDCS was associated with greater improvements in working memory reaction time compared to control (p = 0.007). Reaction time improvement correlated significantly with the degree of connectivity change between the right DLPFC and the left anterior insula (p = 0.02). Conclusion: Anodal tDCS improved reaction time on an online working memory task in a mmTBI population, and decreased connectivity between executive network and salience network nodes. These findings generate important hypotheses for the mechanism of recovery from PPS after mild-moderate TBI.

Transcranial direct current stimulation improves naming reaction time in fluent aphasia: a double-blind, sham-controlled study.

BACKGROUND AND PURPOSE: Previous evidence suggests that anodal transcranial direct current stimulation (A-tDCS) applied to the left hemisphere can improve aphasic participants' ability to name common objects. The current study further examined this issue in a more tightly controlled experiment in participants with fluent aphasia. METHODS: We examined the effect of A-tDCS on reaction time during overt picture naming in 8 chronic stroke participants. Anode electrode placement targeted perilesional brain regions that showed the greatest activation on a pretreatment functional MRI scan administered during overt picture naming with the reference cathode electrode placed on the contralateral forehead. A-tDCS (1 mA; 20-minute) was compared with sham tDCS (S-tDCS) in a crossover design. Participants received 10 sessions of computerized anomia treatment; 5 sessions included A-tDCS and 5 included S-tDCS. RESULTS: Coupling A-tDCS with behavioral language treatment reduced reaction time during naming of trained items immediately posttreatment (Z=1.96, P=0.025) and at subsequent testing 3 weeks later (Z=2.52, P=0.006). CONCLUSIONS: A-tDCS administered during language treatment decreased processing time during picture naming by fluent aphasic participants. Additional studies combining A-tDCS, an inexpensive method with no reported serious side effects, with behavioral language therapy are recommended.

Spectral Resting-State EEG (rsEEG) in Chronic Aphasia Is Reliable, Sensitive, and Correlates With Functional Behavior.

We investigated spectral resting-state EEG in persons with chronic stroke-induced aphasia to determine its reliability, sensitivity, and relationship to functional behaviors. Resting-state EEG has not yet been characterized in this population and was selected given the demonstrated potential of resting-state investigations using other neuroimaging techniques to guide clinical decision-making. Controls and persons with chronic stroke-induced aphasia completed two EEG recording sessions, separated by approximately 1 month, as well as behavioral assessments of language, sensorimotor, and cognitive domains. Power in the classic frequency bands (delta, theta, alpha, and beta) was examined via spectral analysis of resting-state EEG data. Results suggest that power in the theta, alpha, and beta bands is reliable for use as a repeated measure. Significantly greater theta and lower beta power was observed in persons with aphasia (PWAs) than controls. Finally, in PWAs theta power negatively correlated with performance on a discourse informativeness measure, while alpha and beta power positively correlated with performance on the same measure. This indicates that spectral rsEEG slowing observed in PWAs in the chronic stage is pathological and suggests a possible avenue for directly altering brain activation to improve behavioral function. Taken together, these results suggest that spectral resting-state EEG holds promise for sensitive measurement of functioning and change in persons with chronic aphasia. Future studies investigating the utility of these measures as biomarkers of frank or latent aphasic deficits and treatment response in chronic stroke-induced aphasia are warranted.

Main Concept, Sequencing, and Story Grammar Analyses of Cinderella Narratives in a Large Sample of Persons with Aphasia.

Recently, a multilevel analytic approach called Main Concept, Sequencing, and Story Grammar (MSSG) was presented along with preliminary normative information. MSSG analyses leverage the strong psychometrics and rich procedural knowledge of both main concept analysis and story grammar component coding, complementing it with easy-to-obtain sequencing information for a rich understanding of discourse informativeness and macrostructure. This study is the next critical step for demonstrating the clinical usefulness of MSSG's six variables (main concept composite, sequencing, main concept+sequencing, essential story grammar components, total episodic components, and episodic complexity) for persons with aphasia (PWAs). We present descriptive statistical information for MSSG variables for a large sample of PWAs and compare their performance to a large sample of persons not brain injured (PNBIs). We observed significant differences between PWAs and PNBIs for all MSSG variables. These differences occurred at the omnibus group level and for each aphasia subtype, even for PWAs with very mild impairment that is not detected with standardized aphasia assessment. Differences between PWAs and PNBIs were also practically significant, with medium to large effect sizes observed for nearly all aphasia subtypes and MSSG variables. This work deepens our understanding of discourse informativeness and macrostructure in PWAs and further develops an efficient tool for research and clinical use. Future research should investigate ways to expand MSSG analyses and to improve sensitivity and specificity.

Repeated word production is inconsistent in both aphasia and apraxia of speech.

PURPOSE: There is persistent uncertainty about whether sound error consistency is a valid criterion for differentiating between apraxia of speech (AOS) and aphasia with phonemic paraphasia. The purpose of this study was to determine whether speakers with a profile of aphasia and AOS differ in error consistency from speakers with aphasia who do not have AOS. By accounting for differences in overall severity and using a sample size well over three times that of the largest study on the topic to date, our ambition was to resolve the existing controversy. METHOD: We analyzed speech samples from 171 speakers with aphasia and completed error consistency analysis for 137 of them. The experimental task was to repeat four multisyllabic words five times successively. Phonetic transcriptions were coded for four consistency indices (two at the sound-level and two at the word-level). We then used quantitative metrics to assign participants to four diagnostic groups (one aphasia plus AOS group, one aphasia only group, and two groups with intermediate speech profiles). Potential consistency differences were examined with ANCOVA, with error frequency as a continuous covariate. RESULTS: Error frequency was a strong predictor for three of the four consistency metrics. The magnitude of consistency for participants with AOS was either similar or lower compared to that of participants with aphasia only. Despite excellent transcription reliability and moderate to excellent coding reliability, three of the four consistency indices showed limited measurement reliability. DISCUSSION: People with AOS and people with aphasia often produce inconsistent variants of errors when they are asked to repeat challenging words several times sequentially. The finding that error consistency is similar or lower in aphasia with AOS than in aphasia without AOS is incompatible with recommendations that high error consistency be used as a diagnostic criterion for AOS. At the same time, group differences in the opposite direction are not sufficiently systematic to warrant use for differential diagnosis between aphasia with AOS and aphasia with phonemic paraphasia. Greater attention should be given to error propagation when estimating reliability of derived measurements.

Upper and Lower Limb Motor Function Correlates with Ipsilesional Corticospinal Tract and Red Nucleus Structural Integrity in Chronic Stroke: A Cross-Sectional, ROI-Based MRI Study.

BACKGROUND: Structural integrity of the ipsilesional corticospinal tract (CST) is important for upper limb motor recovery after stroke. However, additional neuromechanisms associated with motor function poststroke are less well understood, especially regarding the lower limb. OBJECTIVE: To investigate the neural basis of upper/lower limb motor deficits poststroke by correlating measures of motor function with diffusion tensor imaging-derived indices of white matter integrity (fractional anisotropy (FA), mean diffusivity (MD)) in primary and secondary motor tracts/structures. METHODS: Forty-three individuals with chronic stroke (time poststroke, 64.4 ± 58.8 months) underwent a comprehensive motor assessment and MRI scanning. Correlation and multiple regression analyses were performed to examine relationships between FA/MD in a priori motor tracts/structures and motor function. RESULTS: FA in the ipsilesional CST and red nucleus (RN) was positively correlated with motor function of both the affected upper and lower limb (r = 0.36-0.55, p ≤ 0.01), while only ipsilesional RN FA was associated with gait speed (r = 0.50). Ipsilesional CST FA explained 37.3% of the variance in grip strength (p < 0.001) and 31.5% of the variance in Arm Motricity Index (p = 0.004). Measures of MD were not predictors of motor performance. CONCLUSIONS: Microstructural integrity of the ipsilesional CST is associated with both upper and lower limb motor function poststroke, but appears less important for gait speed. Integrity of the ipsilesional RN was also associated with motor performance, suggesting increased contributions from secondary motor areas may play a role in supporting chronic motor function and could become a target for interventions.

Main concepts for two picture description tasks: An addition to.

BACKGROUND: Proposition analysis of the discourse of persons with aphasia has a long history, yielding important advancements in our understanding of communication impairments in this population. Recently, discourse measures have been considered primary outcome measures, and multiple calls have been made for improved psychometric properties of discourse measures. AIMS: To advance the use of discourse analysis in persons with aphasia by providing Main Concept Analysis checklists and descriptive statistics for healthy control performance on the analysis for the Cat in the Tree and Refused Umbrella narrative tasks utilized in the AphasiaBank database protocol. METHODS & PROCEDURES: Ninety-two control transcripts, stratified into four age groups (20-39 years; 40-59; 60-79; 80+), were downloaded from the AphasiaBank database. Relevant concepts were identified, and those spoken by at least one-third of the control sample were considered to be a main concept. A multi-level coding system was used to determine the accuracy and completeness of the main concepts produced by control speakers. OUTCOMES & RESULTS: Main concept checklists for two discourse tasks are provided. Descriptive statistics are reported and examined to assist readers with evaluation of the normative data. CONCLUSIONS: These checklists provide clinicians and researchers with a tool to reliably assess the discourse of persons with aphasia. They also help address the gap in available psychometric data with which to compare persons with aphasia to healthy controls.

Macrostructural Analyses of Cinderella Narratives in a Large Nonclinical Sample.

Purpose Macrostructural narrative analyses are important clinical measures, revealing age-related declines and disorder-related impairments in the accuracy, completeness, logical sequencing, and organization of content. The current study aims to provide preliminary data on typical aging and psychometric evidence supporting multilevel Main Concept, Sequencing, and Story Grammar (MSSG) analyses that capture these aspects of narratives. Method Transcripts of Cinderella narratives for 92 healthy control participants stratified across four age brackets from the online database AphasiaBank were coded by Richardson and Dalton (2016) for main concept (MC) analysis. In the current study, MSSG analyses were completed for (a) logical sequencing, independently and in combination with MC accuracy and completeness (MC + sequencing), and (b) story grammar organization (i.e., inclusion of episodic components and complexity of episodes). Interrater agreement (99%-100%) revealed highly reliable scoring. Results Descriptive statistics for the typically aging sample are presented for sequencing, MC + sequencing, total episodic components, and episodic complexity. Scores for participants over 60 years of age were lower (poorer) than scores for those 20-59 years of age, supporting the construct validity of score use for identifying age-related declines in performance. Conclusions This study's novel MSSG analyses of narrative production efficiently assess the logical sequencing and story grammar organization of content in healthy controls. Preliminary reliability and validity evidence support the use of all scores to measure age-related changes in narrative macrostructure. Data from this typically aging sample provide a foundation for future research and clinical assessment aimed at quantifying narrative deficits in adults with communication disorders. Supplemental Material https://doi.org/10.23641/asha.12683495.

Developing, Implementing, and Improving Assessment and Treatment Fidelity in Clinical Aphasia Research.

Purpose The purpose of this study was to describe the development and implementation of a fidelity program for an ongoing, multifacility, aphasia intervention study and to explain how initial fidelity measures are being used to improve study integrity. Method A Clinical Core team developed and incorporated a fidelity plan in this study. The aims of the Clinical Core team were to (a) supervise data collection and data management at each clinical site, (b) optimize and monitor assessment fidelity, and (c) optimize and monitor treatment fidelity. Preliminary data are being used to guide ongoing efforts to preserve and improve the fidelity of this intervention study. Results Preliminary results show that specific recruitment strategies help to improve appropriate referrals and that accommodations to participants and their families help to maintain excellent retention. A streamlined and centralized training program assures the reliability of assessors and raters for the study's assessment and treatment protocols. Ongoing monitoring of both assessment and treatment tasks helps to maintain study integrity. Less-than-optimal interrater reliability data for the raters of some of the discourse measures guided the Clinical Core team to address the training and coding inconsistencies in a timely manner. Conclusions The creation of a Clinical Core team is instrumental in developing and implementing a fidelity plan for improved assessment and treatment fidelity. Intentional planning and assignment of study staff to implement and monitor ongoing fidelity measures assures that clinical data are reliable and valid. Ongoing review of the plan shows areas of strengths and weaknesses for continuing adjustments and improvement of study fidelity.

Cerebral Perfusion Effects of Cognitive Training and Transcranial Direct Current Stimulation in Mild-Moderate TBI.

Background: Persistent post-traumatic symptoms (PPS) after traumatic brain injury (TBI) can lead to significant chronic functional impairment. Pseudocontinuous arterial spin labeling (pCASL) has been used in multiple studies to explore changes in cerebral blood flow (CBF) that may result in acute and chronic TBI, and is a promising neuroimaging modality for assessing response to therapies. Methods: Twenty-four subjects with chronic mild-moderate TBI (mmTBI) were enrolled in a pilot study of 10 days of computerized executive function training combined with active or sham anodal transcranial direct current stimulation (tDCS) for treatment of cognitive PPS. Behavioral surveys, neuropsychological testing, and magnetic resonance imaging (MRI) with pCASL sequences to assess global and regional CBF were obtained before and after the training protocol. Results: Robust improvements in depression, anxiety, complex attention, and executive function were seen in both active and sham groups between the baseline and post-treatment visits. Global CBF decreased over time, with differences in regional CBF noted in the right inferior frontal gyrus (IFG). Active stimulation was associated with static or increased CBF in the right IFG, whereas sham was associated with reduced CBF. Neuropsychological performance and behavioral symptoms were not associated with changes in CBF. Discussion: The current study suggests a complex picture between mmTBI, cerebral perfusion, and recovery. Changes in CBF may result from physiologic effect of the intervention, compensatory neural mechanisms, or confounding factors. Limitations include a small sample size and heterogenous injury sample, but these findings suggest promising directions for future studies of cognitive training paradigms in mmTBI.