Behavioral Treatment for Speech and Language in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech: A Systematic Review.

Primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS) are neurodegenerative syndromes characterized by progressive decline in language or speech. There is a growing number of studies investigating speech-language interventions for PPA/PPAOS. An updated systematic evaluation of the treatment evidence is warranted to inform best clinical practice and guide future treatment research. We systematically reviewed the evidence for behavioral treatment for speech and language in this population. Reviewed articles were published in peer-reviewed journals through 31 May 2021. We evaluated level of evidence, reporting quality, and risk of bias using a modified version of the American Speech-Language Hearing Association (ASHA) Levels of Evidence, an appraisal point system, additional reporting quality and internal/external validity items, and, as appropriate, the Single Case Experimental Design Scale or the Physiotherapy Evidence Database - PsycBITE Rating Scale for Randomized and Non-Randomized Controlled Trials. Results were synthesized using quantitative summaries and narrative review. A total of 103 studies reported treatment outcomes for 626 individuals with PPA; no studies used the diagnostic label PPAOS. Most studies evaluated interventions for word retrieval. The highest-quality evidence was provided by 45 experimental and quasi-experimental studies (16 controlled group studies, 29 single-subject designs). All (k = 45/45) reported improvement on a primary outcome measure; most reported generalization (k = 34/43), maintenance (k = 34/39), or social validity (k = 17/19) of treatment for at least one participant. The available evidence supports speech-language intervention for persons with PPA; however, treatment for PPAOS awaits systematic investigation. Implications and limitations of the evidence and the review are discussed.

Interprofessional collaboration and communication to facilitate implementation of cognitive rehabilitation in persons with brain injury.

Cognitive rehabilitation encompasses therapeutic services directed at improving cognitive functioning and functional abilities in individuals with brain injury. The term cognitive rehabilitation, however, is often broadly defined, and interventions delivered by individual disciplines may vary in their conceptualizations. This paper, written by an interprofessional collaborative group of speech-language pathologists and rehabilitation psychologists/ neuropsychologists identifies challenges in interprofessional rehabilitation of cognitive problems as well as solutions for addressing those challenges. Specifically, the challenge of defining elements of cognitive rehabilitation is addressed with a recommendation for interprofessional training and development of a shared perspective; the problem of "siloed" care is addressed by recommendations for consistent and considerable efforts at interprofessional communication, use of shared language and emphasis on health literacy; and the challenge of access to collaborative care is addressed with the recommendation to increase utilization of telerehabilitation interventions. Our goal is to empower clinicians to not only turn to evidence-based practice to address patient needs, but to go further in implementing the evidence base by facilitating true collaborative interdisciplinary services via improved knowledge of best practice, and advocacy avenues within systems of care. Such an approach will maximize the ability of rehabilitation professionals to provide meaningful, person-centered interventions that will maximize patient outcomes.

Integrated Discourse Therapy After Glioblastoma: A Case Report of Face-To-Face and Tele-NeuroRehabilitation Treatment Delivery.

Background: Language and communication impairments are among the most frequently reported long-term behavioral consequences of brain tumor. Such deficits may persist long after a patient has been discharged from the hospital and can significantly impact return to work, resumption of prior social roles, and interpersonal relations, as well as full engagement in leisure activities. While considerable research has centered on identifying and describing communication impairments in brain tumor survivors, relatively little research has investigated language therapy for this population. Aims: This report (1) reviews the literature and describes the language and cognitive-communicative profile of a 35-year-old man 6 years post glioblastoma excision with subsequent chemo- and radiation therapies; (2) presents cognitive-communication outcome data for this individual following an integrated discourse therapy; and (3) assesses treatment feasibility in face-to-face (F2F) and tele-neurorehabilitation (TNR) contexts. Methods: A battery of tests and weekly conversation probes were administered to evaluate baseline performance and potential changes associated with F2F and TNR treatment delivery. Integrated Conversation Therapy (ICT) was administered across four alternating (F2F and TNR) treatment blocks over 2 months. ICT is a solution-focused discourse intervention that simultaneously targets word finding, sentence processing, and authentic patient-selected conversational interactions. Results: Although the participant presented with long term-language impairments that were clinically distinct from stroke-associated aphasia, statistically significant post-treatment gains (>2 SEM) were evident following F2F and TNR treatment delivery on standardized measures of apraxia, discourse production, verbal memory, and self-ratings of discourse production, communication, and living with aphasia. While objective measures of treatment effect size (probes of CIU discourse data) were consistent across F2F and TNR delivery models, results of a satisfaction survey indicated a slight but statistically significant participant preference for TNR treatment delivery. Conclusions: This study provides preliminary support for F2F and TNR delivery of ICT discourse intervention for glioblastoma survivors. It also highlights the need for more research specifically dedicated to language therapy for this population.

Interpreting Mini-Mental State Examination Performance in Highly Proficient Bilingual Spanish-English and Asian Indian-English Speakers: Demographic Adjustments, Item Analyses, and Supplemental Measures.

Purpose: Performance on the Mini-Mental State Examination (MMSE), among the most widely used global screens of adult cognitive status, is affected by demographic variables including age, education, and ethnicity. This study extends prior research by examining the specific effects of bilingualism on MMSE performance. Method: Sixty independent community-dwelling monolingual and bilingual adults were recruited from eastern and western regions of the United States in this cross-sectional group study. Independent sample t tests were used to compare 2 bilingual groups (Spanish-English and Asian Indian-English) with matched monolingual speakers on the MMSE, demographically adjusted MMSE scores, MMSE item scores, and a nonverbal cognitive measure. Regression analyses were also performed to determine whether language proficiency predicted MMSE performance in both groups of bilingual speakers. Results: Group differences were evident on the MMSE, on demographically adjusted MMSE scores, and on a small subset of individual MMSE items. Scores on a standardized screen of language proficiency predicted a significant proportion of the variance in the MMSE scores of both bilingual groups. Conclusions: Bilingual speakers demonstrated distinct performance profiles on the MMSE. Results suggest that supplementing the MMSE with a language screen, administering a nonverbal measure, and/or evaluating item-based patterns of performance may assist with test interpretation for this population.

Comparison of animal, action and phonemic fluency in aphasia.

BACKGROUND: The ability to generate words that follow certain constraints, or verbal fluency, is a sensitive indicator of neurocognitive impairment, and is impacted by a variety of variables. AIMS: To investigate the effect of post-stroke aphasia, elicitation category and linguistic variables on verbal fluency performance. METHODS & PROCEDURES: Twenty-eight persons with aphasia (PWA) with a single left-hemisphere lesion and 40 age-matched neurotypical community-dwelling adults were administered three verbal fluency tasks: two semantic (animals and actions) and one phonemic (the letters F, A and S). Data analysis included comparison of total scores, clusters and perseverations. Individual responses were coded for frequency of occurrence, age of acquisition and syllable length to investigate qualitative differences in word generation. OUTCOMES & RESULTS: PWA performed worse than neurotypical participants across all verbal fluency tasks, and animal fluency scores were farthest from neurotypical performance. PWAs' animal and action fluency were correlated with other language measures, while phonemic fluency was uncorrelated with language measures. While some PWAs showed dissociations between verbal fluency tasks, the dissociations did not pattern along with aphasia fluency. PWAs produced fewer clusters and responses with higher word frequency across all three verbal fluency tasks. Responses had earlier age of acquisition and shorter word length for animal and phonemic fluency, but not action fluency. CONCLUSIONS & IMPLICATIONS: Verbal fluency, particularly animal fluency, is sensitive to even mild aphasia. PWA produced lexically simpler responses than their neurotypical peers. This study identifies the relevance of qualitative analysis of verbal fluency responses.

Integrated training for aphasia: an application of part-whole learning to treat lexical retrieval, sentence production, and discourse-level communications in three cases of nonfluent aphasia.

PURPOSE: The purpose of this study was to evaluate integrated training for aphasia (ITA), a multicomponent language-production treatment based on part-whole learning that systematically trains lexical retrieval, sentence production, and discourse-level communications. Specific research objectives were to evaluate acquisition of target structures, statistical parameters associated with learning variables, treatment generalization, and the efficacy of individual treatment components. METHOD: ITA was administered to 3 individuals with nonfluent aphasia following a multiple-baseline, across-behaviors design. Effect size and correlational coefficients were computed to assess acquisition, generalization, and maintenance of target structures. Standardized tests and a treatment efficacy questionnaire were also completed. RESULTS: A significant treatment effect was found in 2 of the 3 participants. In addition, as is seen in normal skill acquisition, practice time and error rate were significantly correlated. All participants demonstrated evidence of generalization on standardized language measures. Only 1 participant improved, however, on the communication measures. Results of the treatment component analysis revealed significant differences in the perceived efficacy of individual therapy tasks. CONCLUSIONS: Findings add to the evidence supporting multicomponent aphasia treatments, provide preliminary support for ITA and the application of a part-whole learning approach, and suggest that specific treatment components may contribute differentially to outcomes and generalization effects.

Agrammatism in Jordanian-Arabic speakers.

The studies of agrammatism show that not all morpho-syntactic elements are impaired to the same degree and that some of this variation may be due to language-specific differences. This study investigated the production of morpho-syntactic elements in 15 Jordanian-Arabic (JA) speaking individuals with agrammatism and 15 age-matched neurologically healthy individuals. Two experiments were conducted to examine the production of complementizer, tense, agreement and negation morphology in JA. The results indicated that the speakers of JA with agrammatism had marked dissociations in producing specific morpho-syntactic elements. The observed impairment patterns overlapped, in many respects, with those observed in other linguistic groups. The findings are discussed with respect to current theories of agrammatism, including both morpho-syntactic and computational accounts.

Neural correlates of covert and overt production of tense and agreement morphology: Evidence from fMRI.

Most neuroimaging studies examining verb morphology have focused on verb tense, with fewer examining agreement morphology, and no previous fMRI studies have investigated distinctions between past and present tense inflection. However, models of language representation and processing suggest differences in where these inflections are instantiated in the phrase structure as well as differences in the linguistic functions they serve, suggesting unique neural networks for these forms. In addition, results of available neuroimaging studies of grammatical morphology vary considerably due to methodological differences. Some studies have used overt production tasks, whereas others have used covert tasks. In the present study we examined brain activation associated with past tense and present tense/agreement morphology under overt and covert production conditions in 13 healthy adults using an event-related functional magnetic resonance imaging (fMRI) design. Production of verbs inflected for past tense (V + -ed) and present tense/agreement (V -s) was elicited using temporal adverbs (i.e. Yesterday, Nowadays). Results showed that in healthy adults inflecting both past tense and agreement morphology (compared to a verb stem production condition) recruited not only left inferior frontal structures, but also motor and premotor cortices, and posterior parietal regions. Activation also was observed in the basal ganglia, thalamus, and the cingulate gyrus. Past tense and present tense/agreement recruited partially overlapping tissue in these regions, with distinctions observed for the two forms in frontal and parietal brain areas. We also found that activation varied with task demands, with more extensive frontal activation noted in the overt compared to the covert verb inflection task. These results are consistent with the hypothesis that the neural signatures for verb inflection differ from that for verb stems alone and involve a distributed frontal and parietal network of brain regions. Further, the neural tissue recruited for instantiation of past tense versus present tense/agreement morphology is distinct, supporting linguistic theories that differentiate the two forms.

Functional category production in English agrammatism.

BACKGROUND: Individuals with agrammatism show selective deficits in functional categories. The Tree Pruning Hypothesis (TPH; Friedmann & Grodzinsky, 1997) suggests that this results from inability to project certain nodes in the syntactic tree. On this account, higher nodes in the tree are more vulnerable than lower ones. Other theories, however, suggest that functional category impairments can be explained in the context of a morphological deficit (e.g., Arabatzi & Edwards, 2002; Penke, 2003; Thompson, Fix, Gitelman, 2002). AIMS: This study examined production of complementizers, tense, and agreement morphology in four English-speaking agrammatic participants to test the hierarchical nature of functional category deficits. The consistency of verb inflection errors was also tested under conditions examining a minimal set versus a full array of English inflected forms. MATERIALS #ENTITYSTARTX00026; PROCEDURES: In experiment 1, participants were asked to produce sentences by using a complementizer (i.e. whether, that, and if), a tense (-ed) or agreement marker (-s), in structured sentence elicitation tasks. In experiment 2, the participants' production of both finite and nonfinite verb inflection forms was examined. OUTCOME #ENTITYSTARTX00026; RESULTS: All participants produced complex sentences successfully using a complementizer, indicating intact projection to the Complementizer Phrase (CP). As for tense and agreement (structures within the Inflection Phrase (IP)), the agrammatic speakers were impaired in both categories and they showed higher scores in nonfinite vs. finite verb conditions. Further, their errors were dominated by substitutions, rather than omissions, with various non-target morphemes. CONCLUSIONS: Our agrammatic participants' deficits are morphological, rather than syntactic. The participants were able to project to the upper most structure, CP. They showed the ability to project verb inflection and to implement inflectional rules in their grammar. However, instantiation of grammatical markers sometimes failed to operate, resulting in incorrect inflectional forms. These findings suggest that within the domain of functional categories, IP- and CP-level deficits may result from disruption of differing underlying mechanisms and, therefore, they may require separate treatment strategies.

Judgment of functional morphology in agrammatic aphasia.

Individuals with agrammatic Broca's aphasia show deficits in production of functional morphemes like complementizers (e.g., that and if) and tense and agreement markers (e.g., -ed and -s), with complementizers often being more impaired than verbal morphology. However, there has been comparatively little work examining patients' ability to comprehend or judge the grammaticality of these morphemes. This paper investigates comprehension of complementizers and verb inflections in two timed grammaticality-judgment experiments. In Experiment 1, participants with agrammatic Broca's aphasia and grammatical-morphology production deficits (n=10) and unimpaired controls (n=10) heard complement clause sentences, subject relative clause sentences, and conjoined sentences. In Experiment 2, the same participants heard sentences with finite auxiliaries, sentences with finite main verbs, and sentences with uninflected verbs. Results showed above-chance accuracy in aphasic participants' judgments for complementizer sentences in Experiment 1, but chance performance for verb inflections in Experiment 2. This pattern held regardless of whether the verb inflections were affixes or free-standing auxiliaries. Implications of these results for theories of agrammatic morphological impairments, including feature underspecification accounts (Wenzlaff & Clahsen, 2004; Burchert, Swoboda-Moll & DeBleser, 2005a) and hierarchical structure-based accounts (Friedmann & Grodzinsky, 1997; Izvorski & Ullman, 1999), are discussed.

A psychometric analysis of functional category production in English agrammatic narratives.

Hierarchical models of agrammatism propose that sentence production deficits can be accounted for in terms of clausal syntactic structure [Friedmann, N., & Grodzinsky, Y. (1997). Tense and agreement in agrammatic production: Pruning the syntactic tree. Brain and Language, 56, 397-425; Hagiwara, H. (1995). The breakdown of functional categories and the economy of derivation. Brain and Language, 50, 92-116]. Such theories predict that morpho-syntactic elements associated with higher nodes in the syntactic tree (complementizers and verb inflections) will be more impaired than elements associated with lower structural positions (negation markers and aspectual verb forms). While this hypothesis has been supported by the results of several studies [Benedet, M. J., Christiansen, J. A., & Goodglass, H. (1998). A cross-linguistic study of grammatical morphology in Spanish- and English-speaking agrammatic patients. Cortex, 34, 309-336; Friedmann, N. (2001). Agrammatism and the psychological reality of the syntactic tree. Journal of Psycholinguistic Research, 30, 71-88; Friedmann, N. (2002). Question production in agrammatism: The tree pruning hypothesis. Brain and Language, 80, 160-187], it has also been challenged on several grounds [Burchert, F., Swoboda-Moll, M., & De Bleser, R. (2005a). Tense and agreement dissociations in German agrammatic speakers: Underspecification vs. hierarchy. Brain and Language, 94, 188-199; Lee, M. (2003). Dissociations among functional categories in Korean agrammatism. Brain and Language, 84, 170-188; Lee, J., Milman, L. H., & Thompson, C. K. (2005). Functional category production in agrammatic speech. Brain and Language, 95, 123-124]. In this paper the question of hierarchical structure was re-examined within the framework of Item Response Theory [IRT, Rasch, G. (1980). Probabilistic models for some intelligence and attainment tests (Expanded ed.). Chicago: University of Chicago Press]. IRT is a probabilistic model widely used in the field of psychometrics to model behavioral constructs as numeric variables. In this study we examined production of functional categories (complementizers, verb inflections, negation markers, and aspectual verb forms) in narrative samples elicited from 18 individuals diagnosed with nonfluent aphasia and 18 matched controls. Data from the aphasic participants were entered into an IRT analysis to test (1) whether production of clausal functional categories can be represented as a variable on a numeric scale; and (2) whether production patterns were consistent with hierarchical syntactic structure. Pearson r correlation coefficients were also computed to determine whether there was a relation between functional category production and other indices of language performance. Results indicate that functional category production can be modeled as a numeric variable using IRT. Furthermore, although variability was observed across individuals, consistent patterns were evident when the data were interpreted within a probabilistic framework. Although functional category production was moderately correlated with a second measure of clausal structure (clause length), it was not correlated with more distant language constructs (noun/verb ratio and WAB A.Q.). These results suggest that functional category production is related to some, but not all, measures of agrammatic language performance.

Initial validity and reliability of the SCCAN: using tailored testing to assess adult cognition and communication.

PURPOSE: The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; L. Milman & A. Holland, 2007) was developed in the hospital setting to address changes in assessment practice. The SCCAN was designed to provide an overview of impairment and activity limitations across 8 cognitive scales (Speech Comprehension, Oral Expression, Reading, Writing, Orientation, Attention, Memory, and Problem Solving). The scales were developed using item response theory so that tailored testing could be implemented to reduce test administration time. This research investigated the validity and reliability of the SCCAN. METHOD: A battery of neuropsychological tests was administered to 40 neurologically healthy control participants and 51 participants diagnosed with left-hemisphere pathology, right-hemisphere pathology, or probable Alzheimer's disease. Analyses were performed to assess test sensitivity and specificity, construct validity, administration time, and reliability. RESULTS: The test accurately classified 95% of the control participants and 98% of the participants diagnosed with neurological disorders. Results indicate that the test also differentiated the performance profiles of the 3 clinical populations. In addition, test scores correlated significantly with external measures of the same cognitive areas. Mean administration time was 34 min. Test-retest stability (r = .96, p < .001) and internal consistency (r = .99, p < .001) coefficients were both significant, indicating that tailored testing procedures generated reliable test scores.

fMRI variability and the localization of languages in the bilingual brain.

The cerebral localization of multiple languages is a topic of active research. This study presents a method for assessing whether partial overlap of active voxels reflects differential language localization, or simply the variability known to occur with multiple runs of the same task in fMRI studies. Two groups of bilingual subjects (early and later learners of L2) performed word fluency and sentence generation tasks in both languages. The degree of separation for regions of activation did not exceed that associated with run-to-run variability for either task or either group. Early bilinguals, however, showed greater total numbers of active voxels than Late bilinguals for both tasks. This effect occurred despite a lack of a behavioral performance differences by the two groups.