[Transcranial direct current stimulation to enhance training effectiveness in chronic poststroke aphasia-A challenge for recruiting participants]. / Transkranielle Gleichstromstimulation zur Verbesserung der Trainingseffektivität bei chronischer Aphasie nach Schlaganfall ­ wie gelingt die Studienrekrutierung Betroffener?

INTRODUCTION/BACKGROUND: DC_TRAIN_APHASIA is an ongoing multicenter, randomized controlled trial, conducted since November 2019 under the lead of the University Medicine Greifswald (ClinicalTrials.gov Identifier: NCT03930121). The study seeks to determine whether adjuvant transcranial direct current stimulation (tDCS) can increase the effectiveness of a 3­week treatment with intensive speech-language therapy in chronic post-stroke aphasia. MATERIAL AND METHOD: Until the end of 2024, a total of 130 patients are to be included in Germany. Recruitment has been a challenge throughout the study and substantial efforts went into devising innovative recruiting approaches. Standard recruitment strategies were used, such as directly approaching people with aphasia in clinical settings, inpatient and outpatient language rehabilitation facilities, and patient support and advocacy groups, alongside more innovative techniques including radio commercials, dissemination of study information via national television and social media platforms. PROVISIONAL RESULTS: Up until now, 110 patients have been included into the study. The largest short-term response was achieved via television and radio. The largest long-term response was obtained through recruitment via logopaedic and neurological facilities, patient support groups, and social media. Participants served as "testimonials", expressing that they were satisfied with the therapy and the tDCS application. DISCUSSION: The multicenter study DC_TRAIN_APHASIA aims to provide evidence on tDCS as an adjuvant application to increase the effect size of intensive speech-language therapy in chronic post-stroke aphasia. The present review may guide future studies in recruiting samples that involve people with impaired communicative abilities.

The prevalence of apraxia of speech in chronic aphasia after stroke: A bayesian hierarchical analysis.

Apraxia of speech is a motor speech disorder that occurs after lesions to the left cerebral hemisphere, most often concomitant with aphasia. It requires specific approaches in the study of its physiological and neuroanatomical basis and special expertise in clinical care. Knowing its prevalence in patients with aphasia after stroke is therefore relevant for planning specific resources in clinical research and in health care provision. Systematic studies of the frequency of this condition are lacking. We examined the frequency of apraxia of speech in a representative sample of 156 patients with chronic post-stroke aphasia. Three experts classified the patients' speech by best-practice auditory-perceptual methods. Bayesian hierarchical models were fitted to obtain probability distributions for prevalence estimates. A prior distribution was calculated in two steps, including Bayesian models for published frequency data (step 1) and prevalence estimates from experienced clinicians (step 2). Separate models were fitted for different severity ranges. Overall, a prevalence rate of .44 [.30, .58] was obtained. When only moderate and severe cases were taken into account, the rate was .35 [.23, .49]. After a further restriction to only severe impairment, prevalence dropped to .22 [.12, .34]. Patients identified with apraxia of speech had suffered more severe strokes according to clinical criteria and had more severe aphasias. The presence of apraxia of speech was predicted by the articulation/prosody and syntax rating scales of the Aachen Aphasia Test. Lower prevalence estimates published earlier are probably biased by low sensitivity of assessment instruments for mild speech impairment.

Transcranial Direct Current Stimulation to Enhance Training Effectiveness in Chronic Post-Stroke Aphasia: A Randomized Controlled Trial Protocol.

Background: Intensive speech-language therapy (SLT) can promote recovery from chronic post-stroke aphasia, a major consequence of stroke. However, effect sizes of intensive SLT are moderate, potentially reflecting a physiological limit of training-induced progress. Transcranial direct current stimulation (tDCS) is an easy-to-use, well-tolerated and low-cost approach that may enhance effectiveness of intensive SLT. In a recent phase-II randomized controlled trial, 26 individuals with chronic post-stroke aphasia received intensive SLT combined with anodal-tDCS of the left primary motor cortex (M1), resulting in improved naming and proxy-rated communication ability, with medium-to-large effect sizes. Aims: The proposed protocol seeks to establish the incremental benefit from anodal-tDCS of M1 in a phase-III randomized controlled trial with adequate power, ecologically valid outcomes, and evidence-based SLT. Methods: The planned study is a prospective randomized placebo-controlled (using sham-tDCS), parallel-group, double-blind, multi-center, phase-III superiority trial. A sample of 130 individuals with aphasia at least 6 months post-stroke will be recruited in more than 18 in- and outpatient rehabilitation centers. Outcomes: The primary outcome focuses on communication ability in chronic post-stroke aphasia, as revealed by changes on the Amsterdam-Nijmegen Everyday Language Test (A-scale; primary endpoint: 6-month follow-up; secondary endpoints: immediately after treatment, and 12-month follow-up). Secondary outcomes include measures assessing linguistic-executive skills, attention, memory, emotional well-being, quality of life, health economic costs, and adverse events (endpoints: 6-month follow-up, immediately after treatment, and 12-month follow-up). Discussion: Positive results will increase the quality of life for persons with aphasia and their families while reducing societal costs. After trial completion, a workshop with relevant stakeholders will ensure transfer into best-practice guidelines and successful integration within clinical routine. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03930121.

Cognitive performance under motor demands - On the influence of task difficulty and postural control.

We often walk around when we have to think about something, but suddenly stop when we are confronted with a demanding cognitive task, such as calculating 1540*24. While previous neurophysiological research investigated cognitive and motor performance separately, findings that combine both are rare. To get a deeper understanding of the influence of motor demands as well as the difficulty of a simultaneously performed cognitive task, we investigated 20 healthy individuals. Participants performed two cognitive tasks with different levels of difficulty while sitting or standing on one leg. In addition to behavioral data, we recorded the electroencephalogram from 26Ag/AgCI scalp electrodes. The critical time-windows, predefined by visual inspection, yielded an early (200-300 ms, P2) and a subsequent positivity (350-500 ms, P3). Statistical analysis of the early time window registered a motor × cognition interaction. Resolution of this interaction revealed an effect of the cognitive task in the one-legged stance motor condition, with a more pronounced positivity for the difficult task. No significant differences between cognitive tasks emerged for the simple motor condition. The time-window between 350 and 500 ms registered main effects of the motor task and a trend for the cognitive task. While the influence of cognitive task difficulty (in the P3) is in accordance with previous studies, the motor task effect is specific to one-legged stance (cf. no effects for running in previous research). The motor-cognition interaction found in the P2 indicates that the more difficult motor task (one-legged stance) facilitates cognitive task performance.

Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting.

BACKGROUND: Treatment guidelines for aphasia recommend intensive speech and language therapy for chronic (≥6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke. METHODS: In this multicentre, parallel group, superiority, open-label, blinded-endpoint, randomised controlled trial, patients aged 70 years or younger with aphasia after stroke lasting for 6 months or more were recruited from 19 inpatient or outpatient rehabilitation centres in Germany. An external biostatistician used a computer-generated permuted block randomisation method, stratified by treatment centre, to randomly assign participants to either 3 weeks or more of intensive speech and language therapy (≥10 h per week) or 3 weeks deferral of intensive speech and language therapy. The primary endpoint was between-group difference in the change in verbal communication effectiveness in everyday life scenarios (Amsterdam-Nijmegen Everyday Language Test A-scale) from baseline to immediately after 3 weeks of treatment or treatment deferral. All analyses were done using the modified intention-to-treat population (those who received 1 day or more of intensive treatment or treatment deferral). This study is registered with ClinicalTrials.gov, number NCT01540383. FINDINGS: We randomly assigned 158 patients between April 1, 2012, and May 31, 2014. The modified intention-to-treat population comprised 156 patients (78 per group). Verbal communication was significantly improved from baseline to after intensive speech and language treatment (mean difference 2·61 points [SD 4·94]; 95% CI 1·49 to 3·72), but not from baseline to after treatment deferral (-0·03 points [4·04]; -0·94 to 0·88; between-group difference Cohen's d 0·58; p=0·0004). Eight patients had adverse events during therapy or treatment deferral (one car accident [in the control group], two common cold [one patient per group], three gastrointestinal or cardiac symptoms [all intervention group], two recurrent stroke [one in intervention group before initiation of treatment, and one before group assignment had occurred]); all were unrelated to study participation. INTERPRETATION: 3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke, providing an effective evidence-based treatment approach in this population. Future studies should examine the minimum treatment intensity required for meaningful treatment effects, and determine whether treatment effects cumulate over repeated intervention periods. FUNDING: German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Age-Related Changes in Predictive Capacity Versus Internal Model Adaptability: Electrophysiological Evidence that Individual Differences Outweigh Effects of Age.

Hierarchical predictive coding has been identified as a possible unifying principle of brain function, and recent work in cognitive neuroscience has examined how it may be affected by age-related changes. Using language comprehension as a test case, the present study aimed to dissociate age-related changes in prediction generation versus internal model adaptation following a prediction error. Event-related brain potentials (ERPs) were measured in a group of older adults (60-81 years; n = 40) as they read sentences of the form "The opposite of black is white/yellow/nice." Replicating previous work in young adults, results showed a target-related P300 for the expected antonym ("white"; an effect assumed to reflect a prediction match), and a graded N400 effect for the two incongruous conditions (i.e. a larger N400 amplitude for the incongruous continuation not related to the expected antonym, "nice," versus the incongruous associated condition, "yellow"). These effects were followed by a late positivity, again with a larger amplitude in the incongruous non-associated versus incongruous associated condition. Analyses using linear mixed-effects models showed that the target-related P300 effect and the N400 effect for the incongruous non-associated condition were both modulated by age, thus suggesting that age-related changes affect both prediction generation and model adaptation. However, effects of age were outweighed by the interindividual variability of ERP responses, as reflected in the high proportion of variance captured by the inclusion of by-condition random slopes for participants and items. We thus argue that - at both a neurophysiological and a functional level - the notion of general differences between language processing in young and older adults may only be of limited use, and that future research should seek to better understand the causes of interindividual variability in the ERP responses of older adults and its relation to cognitive performance.

FCET2EC (From controlled experimental trial to = 2 everyday communication): How effective is intensive integrative therapy for stroke-induced chronic aphasia under routine clinical conditions? A study protocol for a randomized controlled trial.

BACKGROUND: Therapy guidelines recommend speech and language therapy (SLT) as the "gold standard" for aphasia treatment. Treatment intensity (i.e., ≥5 hours of SLT per week) is a key predictor of SLT outcome. The scientific evidence to support the efficacy of SLT is unsatisfactory to date given the lack of randomized controlled trials (RCT), particularly with respect to chronic aphasia (lasting for >6 months after initial stroke). This randomized waiting list-controlled multi-centre trial examines whether intensive integrative language therapy provided in routine in- and outpatient clinical settings is effective in improving everyday communication in chronic post-stroke aphasia. METHODS/DESIGN: Participants are men and women aged 18 to 70 years, at least 6 months post an ischemic or haemorrhagic stroke resulting in persisting language impairment (i.e., chronic aphasia); 220 patients will be screened for participation, with the goal of including at least 126 patients during the 26-month recruitment period. Basic language production and comprehension abilities need to be preserved (as assessed by the Aachen Aphasia Test).Therapy consists of language-systematic and communicative-pragmatic exercises for at least 2 hours/day and at least 10 hours/week, plus at least 1 hour self-administered training per day, for at least three weeks. Contents of therapy are adapted to patients' individual impairment profiles.Prior to and immediately following the therapy/waiting period, patients' individual language abilities are assessed via primary and secondary outcome measures. The primary (blinded) outcome measure is the A-scale (informational content, or 'understandability', of the message) of the Amsterdam-Nijmegen Everyday Language Test (ANELT), a standardized measure of functional communication ability. Secondary (unblinded) outcome measures are language-systematic and communicative-pragmatic language screenings and questionnaires assessing life quality as viewed by the patient as well as a relative.The primary analysis tests for differences between the therapy group and an untreated (waiting list) control group with respect to pre- versus post 3-week-therapy (or waiting period, respectively) scores on the ANELT A-scale. Statistical between-group comparisons of primary and secondary outcome measures will be conducted in intention-to-treat analyses.Long-term stability of treatment effects will be assessed six months post intensive SLT (primary and secondary endpoints). TRIAL REGISTRATION: Registered in ClinicalTrials.gov with the Identifier NCT01540383.

Prominence vs. aboutness in sequencing: a functional distinction within the left inferior frontal gyrus.

Prior research on the neural bases of syntactic comprehension suggests that activation in the left inferior frontal gyrus (lIFG) correlates with the processing of word order variations. However, there are inconsistencies with respect to the specific subregion within the IFG that is implicated by these findings: the pars opercularis or the pars triangularis. Here, we examined the hypothesis that the dissociation between pars opercularis and pars triangularis activation may reflect functional differences between clause-medial and clause-initial word order permutations, respectively. To this end, we directly compared clause-medial and clause-initial object-before-subject orders in German in a within-participants, event-related fMRI design. Our results showed increased activation for object-initial sentences in a bilateral network of frontal, temporal and subcortical regions. Within the lIFG, posterior and inferior subregions showed only a main effect of word order, whereas more anterior and superior subregions showed effects of word order and sentence type, with higher activation for sentences with an argument in the clause-initial position. These findings are interpreted as evidence for a functional gradation of sequence processing within the left IFG: posterior subportions correlate with argument prominence-based (local) aspects of sequencing, while anterior subportions correlate with aboutness-based aspects of sequencing, which are crucial in linking the current sentence to the wider discourse. This proposal appears compatible with more general hypotheses about information processing gradients in prefrontal cortex (Koechlin & Summerfield, 2007).

The role of the posterior superior temporal sulcus in the processing of unmarked transitivity.

Is it living or not? The ability to differentiate between animate and inanimate entities is of considerable value in everyday life, since it allows for the dissociation of individuals that may willfully cause an action from objects that cannot. The present fMRI study aimed to shed light on the neural correlates of animacy at a relational-interpretive level, i.e. on the role of animacy in the establishment of relations between entities that are more or less likely to cause an event and differ in their potential to act volitionally. To this end, we investigated the processing of visually presented transitive German sentences (nominative-accusative structures) in which the factors animacy and argument order were manipulated. The relations between the arguments differed in that the animate subject either acted on an inanimate object (a very natural construction in terms of transitivity) or on an animate object (resulting in a sentence deviating from an unmarked transitive structure). Participants performed an acceptability judgment task. Violations of unmarked transitivity yielded a significant activation increase within the posterior left superior temporal sulcus (pSTS), thus suggesting a specific role of this cortical region in the relational use of animacy information. This result indicates that the influence of animacy as a relational feature differs from the impact of this parameter on the word level and is in line with other neuroimaging studies showing an engagement of the pSTS when a matching between syntax and semantics is required. A comparison between object- and subject-initial conditions further revealed a robust effect of argument order in the pars opercularis of the left inferior frontal gyrus (a subregion of Broca's area), thereby replicating previous findings demonstrating a sensitivity of this region to fine-grained language-specific linearization rules.

Linguistic prominence and Broca's area: the influence of animacy as a linearization principle.

Previous neuroimaging findings suggest a sensitivity of the pars opercularis of the left inferior frontal gyrus (i.e. a core subregion of Broca's area) to a number of linguistic dependencies governing the linear sequencing of information in a sentence (e.g. subjects should precede objects; the participant role hierarchy should be respected). The present study used event-related fMRI to examine the hitherto untested hypothesis that the violation of a linearization principle that is purely semantic in nature (animate arguments should precede inanimate arguments) would also lead to increased pars opercularis activation. To this end, we manipulated the features animacy and argument order in German sentences and found a significant increase of activation in the pars opercularis for a violation of the animacy principle even when the other factors mentioned above were controlled for. This result therefore calls for a "supra-syntactic" account of pars opercularis function in the real-time understanding of sentences.

The emergence of the unmarked: a new perspective on the language-specific function of Broca's area.

A number of neuroimaging studies have implicated an involvement of Broca's area, particularly of the pars opercularis of the left inferior frontal gyrus (IFG), in the processing of complex (permuted) sentences. However, functional interpretations of this region's role range from very general (e.g., in terms of working memory) to highly specific (e.g., as supporting particular types of syntactic operations). A dissociation of these competing accounts is often impossible because in most cases, the language internal complexity of permuted sentence structures is accompanied invariably by increasing costs of a more general cognitive nature (e.g., working memory, task difficulty, and acceptability). We used functional magnetic resonance imaging to explore the precise nature of the pars opercularis activation in the processing of permuted sentences by examining the permutation of pronouns in German. Although clearly involving a permutation operation, sentences with an initial object pronoun behave like simple, subject-initial sentences (e.g., in terms of acceptability) because of a rule stating that pronouns should generally precede non-pro-nominal arguments. The results of the experiment show that in contrast to non-pro-nominal permutations, sentences with a permuted pronoun do not engender enhanced pars opercularis activation. Our findings therefore speak against both language-related working memory and transformation-based accounts of this region's role in sentence comprehension. Rather, we argue that the pars opercularis of the left IFG supports the language-specific linearization of hierarchical linguistic dependencies.