An Exploration of the Impact of Group Treatment for Aphasia on Connected Speech.

OBJECTIVE: Group treatment enables people with aphasia to practise communication skills outside the typical clinician-patient dyad. While there is evidence that this treatment format can improve participation in everyday communication, there is little evidence it impacts linguistic abilities. This project aimed to investigate the effects of 'typical' group treatment on the communication skills of people with aphasia with a focus on word retrieval in discourse. METHODS: Three people with aphasia took part in a 6-week group therapy programme. Each week focused on a different topic, and three topics also received a home programme targeting word retrieval. The six treated topics were compared with two control topics, with regard to language production in connected speech. Semistructured interviews were collected twice prior to treatment and twice following the treatment and analysed using (a) word counts; (b) the profile of word errors and retrieval in speech; (c) a measure of propositional idea density, and (d) perceptual discourse ratings. RESULTS: Two participants showed no significant improvements; one participant showed significant improvement on discourse ratings. CONCLUSIONS: This study provides limited support for group treatment, leading to improved communication as measured by semistructured interviews, even when supplemented with a home programme. We suggest that either group treatment, as implemented here, was not an effective approach for improving communication for our participants and/or that outcome measurement was limited by difficulty assessing changes in connected speech.

Melodic intonation therapy in post-stroke nonfluent aphasia: a randomized pilot trial.

OBJECTIVE:: To collect data to estimate the sample size of a definitive randomized controlled trial to evaluate the effects of Melodic Intonation Therapy in post-stroke nonfluent aphasia. DESIGN:: A randomized, crossover, interventional pilot trial. SETTING:: Departments of Neurology and Rehabilitation from a university general hospital. PARTICIPANTS:: Stroke survivors with post-stroke nonfluent aphasia. INTERVENTIONS:: Patients randomized to group 1 had treatment with Melodic Intonation Therapy first (12 sessions over six weeks) followed by no treatment; the patients in group 2 started active treatment between three and six months after their inclusion in the study, serving as waiting list controls for the first phase. MAIN MEASURES:: The Communicative Activity Log (CAL) questionnaire and the Boston Diagnostic Aphasia Examination (BDAE) were evaluated at baseline, and at six and 12 weeks. RESULTS:: Twenty patients were included. Four of the patients allocated to group 2 crossed over to group 1, receiving the treatment at first. Intention-to-treat analysis: after adjustment for baseline scores, the mean difference in the CAL evaluation from baseline in the treated group was 8.5 points (95% confidence interval (CI), 0.11-17.0; P = .043), with no significant change in any of the BDAE sections. Per-protocol analysis showed similar results with a clear treatment effect ( P = .043) on the CAL. CONCLUSION:: Melodic Intonation Therapy might have a positive effect on the communication skills of stroke survivors with nonfluent aphasia as measured by the CAL questionnaire. A full-scale trial with at least 27 patients per group is necessary to confirm these results.

The effect of augmented input on the auditory comprehension of narratives for people with aphasia: a pilot investigation.

Augmented input is the strategy of supplementing expressive language with visuographic images, print, gestures, or objects in the environment. The goal of augmented input is to facilitate comprehension of spoken language. The purpose of this study was to evaluate the relative effectiveness of two different augmented input conditions in facilitating auditory comprehension of narrative passages in adults with aphasia. One condition involved the communication partner (clinician) of the adult with aphasia actively pointing (AI-PP) out key content words using visuographic supports. The second condition involved no active pointing (AI-NPP) by the communication partner (i.e., attention was not drawn to the visuographic supports). All 12 participants with aphasia listened to two narratives; one in each condition. Auditory comprehension was measured by assessing participants' accuracy in responding to 15 multiple-choice cloze-type statements related to the narratives. Of the 12 participants, seven gave more accurate responses to comprehension items in the AI-PP condition, four gave more accurate responses in the AI-NPP condition, and one scored the same in both conditions. These differences were not statistically significant (p > 0.05). Communication-partner-referenced augmented input using combined high-context and PCS symbol visuographic supports improved response accuracy for some participants. Continued research is necessary to determine partner involvement with and frequency of augmented input that improve auditory comprehension.

The effectiveness of script training to restore lost communication in a patient with Broca's aphasia.

Aphasia is considered as an acquired neurological disorder of communication, which is characterised by the symptoms on all levels of language dysfunction. The current study was planned to explore the outcomes of script training in a patient with Broca's aphasia through quantitative approach using a single-subject-multiple-baseline research design across behaviours. The probes were obtained during the baseline, treatment, maintenance and generalisation phases for tracking the spoken use of scripted content. All the probes were transcribed verbatim and no value of Cohen's Kappa Coefficient (K) was below 0.61, indicating robust inter-rater reliability. The subject learned all six scripts successively and over 80% of mastery level on all dependent variables was achieved. The largest effect size, above 10.1, was reported for the percent of intelligible scripted words (PISW). Script training was found to be an effective therapy for rejuvenating lost communication of patients with severe Broca's aphasia.

Language specificity of lexical-phonological therapy in bilingual aphasia: A clinical and electrophysiological study.

Based on findings for overlapping representations of bilingual people's first (L1) and second (L2) languages, unilingual therapies of bilingual aphasia have been proposed to benefit the untrained language. However, the generalisation patterns of intra- and cross-language and phonological therapy and their neural bases remain unclear. We tested whether the effects of an intensive lexical-phonological training (LPT) in L2 transferred to L1 word production in a Persian-French bilingual stroke patient with Broca's aphasia. Language performance was assessed using the Bilingual Aphasia Test, a 144-item picture naming (PN) task and a word-picture verification (WPV) task. Electroencephalography (EEG) was recorded during PN and WPV in both languages before and after an LPT in French on a wordlist from the PN task. After the therapy, naming improved only for the treated L2 items. The naming performance improved neither in the untrained L2 items nor in the corresponding items in L1. EEG analyses revealed a Language x Session topographic interaction at 540 ms post-stimulus, driven by a modification of the electrophysiological response to the treated L2 but not L1 items. These results indicate that LPT modified the brain networks engaged in the phonological-phonetic processing during naming only in the trained language for the trained items.

Training-induced improvement of noncanonical sentence production does not generalize to comprehension: evidence for modality-specific processes.

The presence or absence of generalization after treatment can provide important insights into the functional relationship between cognitive processes. The aim of the present study was to investigate the relationship between the cognitive processes that underlie sentence comprehension and production in aphasia. Using data from seven participants who took part in a case-series intervention study that focused on noncanonical sentence production [Stadie et al. (2008). Unambiguous generalization effects after treatment of noncanonical sentence production in German agrammatism. Brain and Language, 104, 211-229], we identified patterns of impairments and generalization effects for the two modalities. Results showed (a) dissociations between sentence structures and modalities before treatment, (b) an absence of cross-modal generalization from production to comprehension after treatment, and (c), a co-occurrence of spared comprehension before treatment and generalization across sentence structures within production after treatment. These findings are in line with the assumption of modality-specific, but interacting, cognitive processes in sentence comprehension and production. More specifically, this interaction is assumed to be unidirectional, allowing treatment-induced improvements in production to be supported by preserved comprehension.

Rehabilitation of poststroke cognition.

Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.

The link between STM and sentence comprehension: a neuropsychological rehabilitation study.

A memory rehabilitation study was conducted with two patients with contrasting impairments in verbal short-term memory (STM): one with impaired phonological STM (pSTM) and one with impaired semantic STM (sSTM). Two treatments were employed, each designed to improve separate aspects of STM: phonological and semantic. The pSTM treatment selectively improved sensitivity to phonological effects in STM, and the sSTM treatment brought about increased lexical effects on verbal STM performance. There was also some evidence of type-specific generalisation to sentence comprehension, in that the pSTM patient showed post-treatment improvement on sentence repetition after the pSTM treatment, and the sSTM patient showed improved sentence anomaly judgement after the sSTM but not the pSTM treatment. The findings are discussed in relation to theories on the components involved in STM, and the role of STM in sentence processing.

Neuronavigated vs. conventional repetitive transcranial magnetic stimulation method for virtual lesioning on the Broca's area.

OBJECTIVES: This study was undertaken to test the hypothesis that repetitive transcranial magnetic stimulation (rTMS) using a neuronavigational TMS system (nTMS) to the Broca's area would elicit greater virtual aphasia than rTMS using the conventional TMS method (cTMS). MATERIALS AND METHODS: Eighteen healthy subjects underwent a randomized crossover experiment to induce virtual aphasia by targeting the Brodmann area 44 and 45 for nTMS, and F3 of international 10-20 system for cTMS. Reaction time for a picture naming task and the reaction duration for a six-digit number naming task were measured before and after each session of stimulation, and compared between the cTMS and nTMS. The stability of the coil positioning on the target was measured by depicting the variability of talairach coordinates (x, y, z) of the sampled stimulation localizations. RESULTS: At baseline, outcome variables were comparable between cTMS and nTMS. nTMS induced significant delays in reaction time from 944.0 ± 203.4 msec to 1304.6 ± 215.7 msec (p < 0.001) and reaction duration from 1780.5 ± 286.8 msec to 1914.9 ± 295.6 msec (p < 0.001) compared with baseline, whereas cTMS showed no significant changes (p = 0.959 and p = 0.179, respectively). The mean talairach space coordinates of nTMS demonstrated greater consistency of localization of stimulation with the target, and the error range relative to the target was narrower for the nTMS compared with the cTMS (p < 0.001). CONCLUSIONS: nTMS leads to more robust neuromodulation of Broca's area, resulting in delayed verbal reaction time as well as more accurate targeting of the intended stimulation location, demonstrating superiority of nTMS over cTMS for therapeutic use of rTMS in neurorehabilitation.

Effects of video modelling on emerging speech in an adult with traumatic brain injury: preliminary findings.

PRIMARY OBJECTIVE: Research has shown that traumatic brain injury (TBI) can affect a person's ability to perform previously learned skills. Dysexecutive syndrome and inattention, for example, alongside a number of other cognitive and behavioural impairments such as memory loss and lack of motivation, significantly affect day-to-day functioning following TBI. This study examined the efficacy of video modelling in emerging speech in an adult male with TBI caused by an assault. RESEARCH DESIGN: In an effort to identify functional relations between this novice intervention and the target behaviour, experimental control was achieved by using within-system research methodology, overcoming difficulties of forming groups for such an highly non-homogeneous population. METHODS AND PROCEDURES: Across a number of conditions, the participant watched a videotape in which another adult modelled a selection of 19 spoken words. When this modelled behaviour was performed in vivo, then generalization across 76 other words in the absence of a videotape took place. MAIN OUTCOMES AND RESULTS: It was revealed that video modelling can promote the performance of previously learned behaviours related to speech, but more significantly it can facilitate the generalization of this verbal behaviour across untrained words. CONCLUSIONS: Video modelling could well be added within the rehabilitation programmes for this population.

Rhythm in disguise: why singing may not hold the key to recovery from aphasia.

The question of whether singing may be helpful for stroke patients with non-fluent aphasia has been debated for many years. However, the role of rhythm in speech recovery appears to have been neglected. In the current lesion study, we aimed to assess the relative importance of melody and rhythm for speech production in 17 non-fluent aphasics. Furthermore, we systematically alternated the lyrics to test for the influence of long-term memory and preserved motor automaticity in formulaic expressions. We controlled for vocal frequency variability, pitch accuracy, rhythmicity, syllable duration, phonetic complexity and other relevant factors, such as learning effects or the acoustic setting. Contrary to some opinion, our data suggest that singing may not be decisive for speech production in non-fluent aphasics. Instead, our results indicate that rhythm may be crucial, particularly for patients with lesions including the basal ganglia. Among the patients we studied, basal ganglia lesions accounted for more than 50% of the variance related to rhythmicity. Our findings therefore suggest that benefits typically attributed to melodic intoning in the past could actually have their roots in rhythm. Moreover, our data indicate that lyric production in non-fluent aphasics may be strongly mediated by long-term memory and motor automaticity, irrespective of whether lyrics are sung or spoken.

Short-term memory treatment: patterns of learning and generalisation to sentence comprehension in a person with aphasia.

Auditory-verbal short-term memory deficits (STM) are prevalent in aphasia and can contribute to sentence comprehension deficits. This study investigated the effectiveness of a novel STM treatment in improving STM (measured with span tasks) and sentence comprehension (measured with the Token Test and the Test for the Reception of Grammar, TROG) in a person with severe aphasia (transcortical motor). In particular, the research questions were: (1) Would STM training improve STM? (2) Would improvements from the STM training generalise to improvements in comprehension of sentences? STM was trained using listening span tasks of serial word recognition. No other language or sentence comprehension skills were trained. Following treatment, STM abilities improved (listening span, forward digit span). There was also evidence of generalisation to untreated sentence comprehension (only on the TROG). Backward digit span, phonological processing and single word comprehension did not improve. Improvements in sentence comprehension may have resulted from resilience to rapid decay of linguistic representations within sentences (words and phrases). This in turn facilitated comprehension.

Voice rehabilitation of Broca's aphasia following total laryngectomy.

Total laryngectomy, as a consequence of carcinoma of the larynx, results in loss of speech function. Cerebrovascular stroke is the leading cause of reduced speech production ability, and thereby communication difficulties. The case is presented of a 60-year-old male patient who suffered stroke five years after a total laryngectomy. Speech rehabilitation was hampered due to the depressive state of the patient. Although contraindicated, the secondary voice prosthesis was implanted. Only at that moment the patient showed willingness and motivation for speech rehabilitation. The aim of this presentation is to demonstrate that not all neurological disorders are contraindicated for implantation of voice prostheses.

Quality of Communication Life (QoCL) In Persons with Expressive Aphasia With And Without Communication Intervention - A Comparative Study.

Background: Communication difficulties in aphasia can result in social isolation, challenges with interpersonal relationships, emotional changes, inability to return to work, and lack of independence. Therefore, intervention is essential particularly in the context of functional communication for persons with aphasia (PwAs). Studies have also indicated that quality of communication life (QoCL) is a valid measure of the impact of communication difficulty on quality of life. Objective: To estimate the relationship between communication intervention and QoCL in individuals with expressive aphasia. Methods and Material: Twenty PwAs were divided into two groups: group I individuals had undergone at least 3 months of speech and language intervention whereas group II individuals did not have any formal communication intervention. Tamil version of the QoCL scale was administered for all participants. Statistical analysis was carried out using Mann-Whitney U test and Spearman's rho correlation coefficient. Results: Individuals with speech and language intervention in group I had higher scores in overall QoCL domains as well as in overall QoL when compared to group II. The results of correlation analysis indicated that individuals with greater therapy duration had significantly high scores. Conclusions: The results prove that communication intervention is necessary for PwAs to improve QoCL and can be used to raise awareness of its importance. The findings can also guide treatment planning, counseling the PwA, and caregivers. It also indicates the importance of using patient-related outcome measures during the intervention process.

Functional Connectivity and Speech Entrainment Speech Entrainment Improves Connectivity Between Anterior and Posterior Cortical Speech Areas in Non-fluent Aphasia.

BACKGROUND: Speech entrainment (SE), the online mimicking of an audio-visual speech model, has been shown to increase speech fluency in individuals with non-fluent aphasia. One theory that may explain why SE improves speech output is that it synchronizes functional connectivity between anterior and posterior language regions to be more similar to that of neurotypical speakers. OBJECTIVES: The present study tested this by measuring functional connectivity between 2 regions shown to be necessary for speech production, and their right hemisphere homologues, in 24 persons with aphasia compared to 20 controls during both free (spontaneous) speech and SE. METHODS: Regional functional connectivity in participants with aphasia were normalized to the control data. Two analyses were then carried out: (1) normalized functional connectivity was compared between persons with aphasia and controls during free speech and SE and (2) stepwise linear models with leave-one-out cross-validation including normed functional connectivity during both tasks and proportion damage to the left hemisphere as independent variables were created for each language score. RESULTS: Left anterior-posterior functional connectivity and left posterior to right anterior functional connectivity were significantly more similar to connectivity of the control group during SE compared to free speech. Additionally, connectivity during free speech was more associated with language measures than connectivity during SE. CONCLUSIONS: Overall, these results suggest that SE promotes normalization of functional connectivity (i.e., return to patterns observed in neurotypical controls), which may explain why individuals with non-fluent aphasia produce more fluent speech during SE compared to spontaneous speech.

Aphasia in border-zone infarcts has a specific initial pattern and good long-term prognosis.

BACKGROUND: While border-zone infarcts (BZI) account for about 10% of strokes, studies on related aphasia are infrequent. The aim of this work was to redefine specifically their early clinical pattern and evolution. METHODS: We prospectively studied consecutive patients referred to our stroke unit within a 2-year period. Cases of aphasia in right-handed patients associated with a MRI confirmed left-sided hemispheric BZI were included. These patients had a standardized language examination in the first 48 h, at discharge from stroke unit and between 6 and 18 months later. RESULTS: Eight patients were included. Three had anterior (MCA/ACA), two posterior (MCA/PCA), two both anterior and posterior, and one bilateral BZI. All our patients initially presented transcortical mixed aphasia, characterized by comprehension and naming difficulties associated with preserved repetition. In all patients, aphasia rapidly improved. It fully recovered within a few days in three patients. Initial improvement was marked, although incomplete in the five remaining patients: their aphasias specifically evolved according to the stroke location toward transcortical motor aphasia for the three patients with anterior BZI and transcortical sensory aphasia for the two patients with posterior BZI. All patients made a full language recovery within 18 months after stroke. CONCLUSIONS: We report a specific aphasic pattern associated with hemispheric BZI, including an excellent long-term outcome. These findings appear relevant to (i) clinically suspect BZI and (ii) plan rehabilitation and inform the patient and his family of likelihood of full language recovery.

'A man paints with his brains and not with his hands' (Michelangelo).

The goals of a post-stroke rehabilitation plan are very specific to each patient. The side of the body affected by hemiplegia can influence the rehabilitation plan, as people with right-sided hemiplegia may also have difficulties with speech and language (aphasia). Because of the aphasia, drawing may remain a crucial instrument of creative expression and the clinical case presented highlights how this goal may also be successfully achieved in the elderly by using the left hand.

Therapy for naming difficulties in bilingual aphasia: which language benefits?

BACKGROUND: The majority of the world's population is bilingual. Yet, therapy studies involving bilingual people with aphasia are rare and have produced conflicting results. One recent study suggested that therapy can assist word retrieval in bilingual aphasia, with effects generalizing to related words in the untreated language. However, this cross-linguistic generalisation only occurred into the person's stronger language (L1). While indicative, these findings were derived from just three participants, and only one received therapy in both languages. AIMS: This study addressed the following questions. Do bilingual people with aphasia respond to naming therapy techniques developed for the monolingual population? Do languages respond differently to therapy and, if so, are gains influenced by language dominance? Does cross-linguistic generalisation occur and does this depend on the therapy approach? Is cross-linguistic generalisation more likely following treatment in L2 or L1? METHODS & PROCEDURES: The study involved five aphasic participants who were bilingual in English and Bengali. Testing showed that their severity and dominance patterns varied, so the study adopted a case series rather than a group design. Each person received two phases of naming therapy, one in Bengali and one in English. Each phase treated two groups of words with semantic and phonological tasks, respectively. The effects of therapy were measured with a picture-naming task involving both treated and untreated (control) items. This was administered in both languages on four occasions: two pre-therapy, one immediately post-therapy and one 4 weeks after therapy had ceased. Testing and therapy in Bengali was administered by bilingual co-workers. OUTCOMES & RESULTS: Four of the five participants made significant gains from at least one episode of therapy. Benefits arose in both languages and from both semantic and phonological tasks. There were three instances of cross-linguistic generalisation, which occurred when items had been treated in the person's dominant language using semantic tasks. CONCLUSIONS & IMPLICATIONS: This study suggests that 'typical' naming treatments can be effective for some bilingual people with aphasia, with both L1 and L2 benefiting. It offers evidence of cross-linguistic generalisation, and suggests that this is most likely to arise from semantic therapy approaches. In contrast to some results in the academic literature, the direction of generalisation was from LI to L2. The theoretical implications of these findings are considered. Finally, the results support the use of bilingual co-workers in therapy delivery.

"Waiting on the words": procedures and outcomes of a drama class for individuals with aphasia.

Drama therapy offers an authentic medium through which people with aphasia can interact and share their experiences. We describe the rationale and procedures of a drama class, informed by the principles and practices of drama therapy, in which individuals with chronic aphasia conceptualized, wrote, and produced a play addressing their experiences of having, living with, and coping with the effects of aphasia. Sessions were cofacilitated by a speech-language pathologist and a drama therapist. We describe the drama activities and techniques in each of four distinct stages of a drama therapy process through which the group transitioned. We also summarize patient-reported outcomes of a representational group of seven participants. Subscales of the Burden of Stroke Scale and the Communication Confidence Rating Scale for Aphasia were administered before and after participation in the 18-week class. Means, standard deviations, and effect sizes were computed. Results indicated perceived improvements in both communication and mood.

Community: the key to building and extending engagement for individuals with aphasia.

The response by the aphasia community to the call of the Life Participation Approach to Aphasia Project Team to offer a framework for the management of aphasia was swift and expansive. Speech pathologists across the world accepted the paradigm shift from language goals within the clinic office to the short-term and long-term life objectives of their clients. The definition of service now included access to those communicative barriers that persons with aphasia face within their community. The recruitment, training, and shaping of that engagement must be individualized for successful (re)engagement. This article aims to present perspective on that process from a program that utilizes a unique center without walls concept.