Telehealth administration of narrative and procedural discourse: A UK and US comparison of traumatic brain injury and matched controls.

BACKGROUND: Impaired discourse production is commonly reported for individuals with traumatic brain injury (TBI). Discourse deficits can negatively impact community integration, return to employment and quality of life. COVID-19 restrictions have reduced in-person assessment services for people with communication impairments. Advances in telehealth may help speech and language therapists (SLTs) to assess monologic discourse more systematically and improve access to services for patients who may find it difficult to attend in-person. AIMS: To examine the feasibility of telehealth administration of narrative and procedural discourse tasks with individuals with TBI and matched controls. METHODS & PROCEDURES: A total of 20 individuals with TBI and 20 healthy controls, aged 18-55 years, were directly recruited from the UK and indirectly recruited from the US. For participants with TBI, time post-injury was at least 3 months with no diagnosis of aphasia. Control participants were matched for sex and as closely as possible for age. Feasibility of measures was based upon the time to administer both narrative tasks, the report of any technological problems, and participant feed. Discourse samples were transcribed verbatim and analysed using story grammar analysis (for narrative discourse) and identification of propositions (for procedural discourse). Interrater reliability was calculated using percentage agreement for 50% of the data. Non-parametric analyses were used to analyse the performance of the two groups. OUTCOMES & RESULTS: Narrative and procedural discourse samples were collected via telehealth in approximately 10 min with no reported technical difficulties or complaints from any participants. For narrative discourse performance, there were significant differences for the TBI and control groups for measures of complete episodes (p < 0.001) and missing episodes (p = 0.005). No significant group differences were noted for any of the procedural discourse measures. CONCLUSIONS & IMPLICATIONS: Results support the feasibility of collecting discourse samples via telehealth. Although the participants' discourse performance distinguished the TBI and control groups on the narrative task, no differences between the groups were noted for the procedural task. The narrative discourse task may have been more difficult than the procedural task, or video cue support reduced the cognitive load of the procedural task. This finding suggests the use of more complex procedural tasks without video cue support may be needed. WHAT THIS PAPER ADDS: What is already known on this subject Although little research has explored the feasibility of administering discourse assessments for individuals with TBI via telehealth, some studies have found that discourse interventions can be feasibly administered via telehealth. It is also well established that individuals with TBI struggle with the supra-structural and macro-linguistic elements of discourse production. Both procedural and narrative discourse tasks have been found to differentiate individuals with TBI from healthy controls. What this paper adds to existing knowledge Few studies have investigated the feasibility of, and procedures for, administering discourse tasks via telehealth. Additionally, the inclusion of multiple types of discourse tasks to parse cognitive-communication abilities is lacking in the current literature. Findings from this study support that narrative and procedural discourse can be feasibly sampled via telehealth and that international collaboration for research on this topic can facilitate such studies. Individuals with TBI performed more poorly on three measures of narrative discourse. No differences between groups were identified for the procedural task. What are the potential or actual clinical implications of this work? Telehealth assessment for discourse provides flexibility for both the individual with TBI and the speech-language therapist and does not compromise the quality of data collected. The administration of discourse tasks and collection of data was not time-consuming and was well accepted by the study participants. Additionally, international research collaboration not only expands potential participation in research but increases the opportunity to recruit and study more diverse groups.

Passive Elaborative Cueing of Retrieval ProcessesFollowing Traumatic Brain Injury.

Purpose: Semantic elaboration is a process in which target information is analyzed in relation to content associated in meaning. The goal of the present study was to examine the use of phrasal cues intended to engage elaborative processes theorized to bolster cognitive performance.Methods: Twenty-two individuals with a history of traumatic brain injury (TBI) and twenty-six neurotypical (NT) individuals were studied. Short phrases intended to elicit elaborative encoding were presented prior to the introduction of a prospective memory task and word-stem completions. Phrases embodied one of three conditions: repeated, semantic, or unrelated information. The stem-completion task was presented between each prospective memory task with fixations serving as cues signaling task completion or functioning as distractors. Event-related potentials (ERPs) were captured during the presentation of word-stems. Following the completion of all word-stems, participants were presented with an old/new recognition task.Results: Linear mixed-effects model analyses revealed a significant effect of condition with respect to word retrieval and recognition memory. Captured ERPs revealed neural signatures resembling a P200.Conclusion: Semantic content increased stimulus saliency, facilitated lexical retrieval, and enhanced retention with the latter process revealing use of semantic cues as a more adept rehearsal strategy than repetition.

Narrative Discourse Performance in Traumatic Brain Injury: Does Story Comprehension Predict Story Retelling?

PURPOSE: Little is known about the relationship between discourse comprehension and production in traumatic brain injury (TBI), especially for spoken language. This study examined to what extent narrative discourse comprehension accounts for narrative discourse production outcomes (story grammar, story completeness). A secondary aim was to provisionally test an assumption of a discourse model, the structure building framework (SBF), that discourse comprehension and production share cognitive processes by investigating the strength of the relationship between them. METHOD: Twenty-one individuals with TBI completed story comprehension and story retelling tasks. Discourse measures included the Discourse Comprehension Test, a picture story comprehension task, story grammar, and story completeness. Correlational and multiple regression analyses were performed using comprehension measures as predictors for production measures. RESULTS: There were significant moderate-to-large correlations between all comprehension and production measures. Comprehension measures approached but did not reach significance for predicting story grammar performance but strongly predicted story completeness outcomes. CONCLUSIONS: The story comprehension measures likely tapped content aspects of discourse more so than organization. Results provided support for a link between content-focused discourse comprehension measures and discourse production outcomes, which may have clinical implications for approaches to discourse intervention. Findings were interpreted as providing preliminary support for the SBF's claim that discourse production deploys the same processes involved in discourse comprehension. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.26338045.

Analysis of narrative discourse structure as an ecologically relevant measure of executive function in adults.

This study examined the narrative discourse production and executive function (EF) abilities of 46 neuro-typical adults (18-98 years old). Two questions were addressed: Is the analysis of narrative structure sensitive to changes associated with aging? & What is the relationship between measures of narrative structure and EF? Narratives were elicited under two conditions and narrative structure was analyzed for the presence of organizing story grammar elements. Narrative structure was significantly correlated with age as well as linguistic and non-linguistic measures of EF. Factor analysis of story structure and EF variables yielded two factors reflecting constructs of output-fluidity and organizational-efficiency. These data suggest that narrative structure and EF represent aspects of goal-directed knowledge that are not bound by a traditional linguistic and non-linguistic division. Thus, narrative structure may represent a global and ecologically valid measure of goal-directed executive function knowledge that is also sensitive to changes associated with typical aging.

Contribution of Working Memory and Inferencing to Narrative Discourse Comprehension and Production in Traumatic Brain Injury.

PURPOSE: The goal of this study was to identify some potential key cognitive and communicative processes underlying narrative discourse ability following traumatic brain injury (TBI). Specifically, this study (a) investigated the contribution of working memory (WM) and inferencing to narrative discourse comprehension and production; (b) tested key assumptions posited by the Structure Building Framework (SBF), a discourse model; and (c) evaluated the potential for inferencing to contribute to discourse ability beyond a shared variance with WM. METHOD: Twenty-one individuals with TBI completed six tasks yielding seven measures: verbal and nonverbal WM updating (WMU-V and WMU-NV, respectively), predictive inferencing, the Discourse Comprehension Test (DCT), a picture story comprehension (PSC) task, and story retelling (story grammar and story completeness). Regression analyses were performed using WM and inferencing as predictors for narrative performance. RESULTS: WM measures were significant predictors of DCT performance and approached significance as predictors of PSC. Inferencing approached significance as a unique predictor for the DCT and story completeness. WMU-V and WMU-NV were highly collinear, and neither WM measure predicted discourse outcomes over and above the other's contribution. CONCLUSIONS: WM was more strongly associated with comprehension processes, whereas inferencing may be associated with both comprehension and production outcomes. Findings were interpreted as supporting SBF assumptions of domain generality of cognitive processes and mechanisms involved in discourse while also challenging assumptions that the same cognitive substrates are marshaled for comprehension and production processes. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.23148647.

Systematic Review of Discourse and Social Communication Interventions in Traumatic Brain Injury.

PURPOSE: This study reviewed the current state of discourse and social communication interventions in traumatic brain injury (TBI) to provide clinically focused guidance about treatment efficacy, treatment approaches by TBI severity, treatment components, and treatment outcome measures. METHOD: Searches were conducted in five electronic databases and reference lists of topical articles for discourse or social communication interventions in TBI published between 2012 and 2021. Search terms reflected three concepts: TBI, treatment, and cognitive-communication. Studies were evaluated for methodological quality using rating scales specific to study design. RESULTS: Seven hundred sixty-seven records were identified, culminating in 21 studies for qualitative synthesis. All approaches resulted in improvement posttreatment, but durability and strength of evidence varied. Five treatment components were identified as "essential" for fostering change. Discourse approaches were generally more effective in mild-to-moderate TBI, whereas social communication approaches were more effective in moderate-to-severe TBI. Communication outcome measures were generally more sensitive to change than measures of other domains of functioning. CONCLUSIONS: The evidence suggests that discourse and social communication treatments are promising for improving communication in TBI. Selection of treatment components and tailoring treatment to the individual are important clinical considerations. Use of at least two proximal outcome measures that evaluate the target behavior and extent of functional generalization may be advantageous. The field would benefit from additional, more rigorous treatment studies to provide a greater understanding of how best to treat cognitive-communicative impairments in people with TBI. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19233516.

Analysis of Discourse Production to Assess Cognitive Communication Deficits Following Mild Traumatic Brain Injury With and Without Posttraumatic Stress.

PURPOSE: Cognitive communication deficits can be difficult to assess in individuals with mild traumatic brain injury (mTBI). However, the use of discourse analysis as a direct and sensitive metric of cognitive communication skills has shown promising clinical utility for other TBI severity levels. This exploratory study investigated discourse production in service members and veterans (SMVs) with uncomplicated mTBI with and without posttraumatic stress disorder (PTSD) and SMVs with neither mTBI or PTSD. METHOD: Fifteen SMVs with mTBI and PTSD, 26 with mTBI, and 25 controls with no brain injury (NBI) and without PTSD were given a wordless picture story to elicit spontaneous discourse. Discourse samples were analyzed for global coherence, word count, the use of negative emotion words, cognitive process words, nonfluencies, and story completeness. RESULTS: Results revealed a significant difference between the mTBI (Mdn = 3.33) and NBI (Mdn = 3.50) groups, χ2(3) = 6.044, p = .017, ε2 = .03, for global coherence. Word count differed significantly between the mTBI + PTSD (Mdn = 135) and NBI (Mdn = 195) groups, χ2(3) = 7.968, p = .006, ε2 = .06. No other group differences were observed. DISCUSSION: Structural features of discourse production may serve as potential markers of cognitive communication deficits in mTBI. Furthermore, PTSD may contribute to verbal fluency deficits in individuals with mTBI. Additional research is needed to develop discourse-related measures that are more sensitive to the effects of mTBI and PTSD.

Primed to cue.

The behavioral effects of lexical priming are well studied in the cognitive sciences. Clinical use of the term and widespread implementation of priming based behavioral interventions has remained limited. This is despite the fact that response-contingent cueing, a behavioral intervention technique used during many cognitive-linguistic interventions, is grounded in theories of priming research. The aim of this manuscript is to connect behavioral performance changes observed following priming with those noted following cueing, providing a theoretical rationale for the therapeutic use of both priming and cueing in language and cognitive interventions. In this review, we establish a conceptual basis for how both primes and cues serve to pre-engage the neural system by triggering the retrieval of linked conceptual knowledge, resulting in faster and more accurate responses. Differences between the two (primes and cues) have been linked to timing and conscious intentional engagement, though these distinctions are often task dependent. Additionally, this paper will provide evidence of the clinical utility of priming. Studies of priming in adults with acquired brain injuries are discussed and clinical interventions based on theories of priming are examined. Furthermore, the present work will briefly detail the inhibitory effects of priming to aid clinicians and researchers in deciding how to pair primes and cues with intended retrieval targets. In summation, the present work is intended to bridge two related fields providing both theoretical and clinical insight with respect to the use of primes and cues.

Conversational Coordination of Articulation Responds to Context: A Clinical Test Case With Traumatic Brain Injury.

Purpose Coordination of communicative behavior supports shared understanding in conversation. The current study brings together analysis of two speech coordination strategies, entrainment and compensation of articulation, in a preliminary investigation into whether strategy organization is shaped by a challenging communicative context-conversing with a person who has a communication disorder. Method As an initial clinical test case, an automated measure of articulatory precision was analyzed in a corpus of spoken dialogue, where a confederate conversed with participants with traumatic brain injury (n = 28) and participants with no brain injury (n = 48). Results Overall, the confederate engaged in significant entrainment and high compensation (hyperarticulation) in conversations with participants with traumatic brain injury relative to significant entrainment and low compensation (hypoarticulation) in conversations with participants with no brain injury. Furthermore, the confederate's articulatory precision changed over the course of the conversations. Conclusions Findings suggest that the organization of conversational coordination is sensitive to context, supporting synergistic models of spoken dialogue. While corpus limitations are acknowledged, these initial results point to differences in the way in which speech strategies are realized in challenging communicative contexts, highlighting a viable and important target for investigation with clinical populations. A framework for investigating speech coordination strategies in tandem and ideas for advancing this line of inquiry serve as key contributions of this work.

Treating underlying attention deficits as a means for improving conversational discourse in individuals with closed head injury: a preliminary study.

BACKGROUND: It is documented that individuals with closed head injury (CHI) demonstrate difficulty with narrative and conversational discourse. Effective conversational discourse requires a complex interaction of linguistic, cognitive, and social abilities [6]. Reduced attention and concentration are among the most common cognitive sequela following CHI [39]. AIMS: The present study investigated whether treatment of attention would facilitate conversational discourse for individuals with CHI. Two treatment protocols were investigated, the first social skills-based, and the second attention-based. It was hypothesized that attention training would improve not only attentional skills but also conversation, however social skills training, would only facilitate conversational skills. METHODS AND PROCEDURES: A single subject multiple treatments comparison design was employed with two individuals who were post-onset of CHI. Treatment effects on conversational performance were calculated using the f statistic [18] for measures of response appropriateness during conversations. OUTCOMES AND RESULTS: Effect sizes suggested that both treatments were active; however, the participants' performances were variable reducing the magnitude of change observed. Results indicated minimal change from baselines, only partially supporting the research hypotheses. CONCLUSIONS: Although the two treatment regimens had some effect on the participants' conversational performances it was not to the extent anticipated. The issues of candidacy for such treatments as well as the importance of incorporating natural contingencies into interventions for conversation training are discussed.

Follow-Up on the Story Goodness Index for Characterizing Discourse Deficits Following Traumatic Brain Injury.

Purpose The Story Goodness Index (SGI) is a hybrid analysis of narrative discourse combining 2 macrostructural measures: story grammar and story completeness. Initially proposed by Lê and colleagues ( Lê, Coelho, Mozeiko, & Grafman, 2011 ), the SGI is intended to characterize the discourse performance of individuals with cognitive-communication disorders. In this study, the SGI was utilized to examine the discourse of 2 groups, one with closed head injuries and another with non-brain injured (NBI) peers. The intent of this study was to ascertain whether the SGI could differentiate the discourse performance of the 2 groups, as was previously reported for individuals with penetrating traumatic brain injury and an NBI comparison group ( Lê, Coelho, Mozeiko, Krueger, & Grafman, 2012 ). Because of the retrospective nature of this study, the wordless visual narrative used to elicit discourse was different from the narrative used by Lê and colleagues (2012) . Method A retrospective analysis of discourse was performed on 55 individuals with a history of closed head injury and 47 NBI socioeconomically matched peers. During the initial assessment, participants were engaged in a narrative retell task. Each participant was shown a wordless picture story and then asked to retell the story to the examiner. Story narratives were reanalyzed for story grammar (organization) and completeness (critical content). Results A significant group difference was noted for the story grammar measure, but not for story completeness. Although the SGI plots depicted the heterogeneity in discourse performance of the 2 groups, a chi-square test of independence revealed no significant association between group membership and SGI quadrant. Conclusions Findings from this study were inconsistent with those of Lê and colleagues. The studies did not use identical SGI protocols; specifically, different picture stimuli were used to elicit the story retells. Therefore, this study cannot be considered a replication. The story used by Lê and colleagues was judged to be more complex, requiring more inference for story interpretation. Future studies should interpret findings within the context of the story stimuli presented.

Treatment Response to a Double Administration of Constraint-Induced Language Therapy in Chronic Aphasia.

Purpose: This study investigated changes in oral-verbal expressive language associated with improvements following 2 treatment periods of constraint-induced language therapy in 4 participants with stroke-induced chronic aphasia. Generalization of treatment to untrained materials and to discourse production was also analyzed, as was the durability of the treatment effect. Method: Participants with aphasia were assessed using standardized measures and discourse tasks at 3 to 4 time points to document behavioral changes throughout each of two 30-hr treatment periods of constraint-induced language therapy. Daily probes of trained and untrained materials were also administered. Results: Despite participant heterogeneity, behavioral results for each person with aphasia indicated a positive response to treatment following each treatment period indicated by performance on standardized tests, trained materials, or both. Treatment effects generalized to some degree to untrained stimuli and to discourse measures and were generally maintained at follow-up testing. Conclusions: Data support the utility of a 2nd treatment period. Results are relevant to rehabilitation in chronic aphasia, confirming that significant language gains continue well past the point of spontaneous recovery and can occur in a relatively short time period. Importantly, changes are not confined to a single treatment period, suggesting that people with aphasia may benefit from multiple doses of high-intensity treatment.

Changes in discourse structure over time following traumatic brain injury.

The objective of the present study was to investigate structural changes in the narrative discourse of individuals with penetrating traumatic brain injury (pTBI) following immediate and delayed story retellings. Additionally, the potential influence of immediate memory, working memory, and executive functions on narrative discourse performance were examined. The narrative discourse of two groups, 123 with pTBI and 44 non-brain injured (NBI), was sampled. Participants were asked to retell a wordless picture story immediately after viewing it and again 30-min later. Story narratives were analyzed using a variety of microlinguistic and macrostructural measures. Results revealed significant group differences of both microlinguistic and macrostructural measures following the immediate retell, but not following the delayed retell. Regression analyses revealed that immediate memory accounted for a modest degree of the explained variance for the production of critical content during narrative discourse. The observed deficits were relatively stable over a short delay (30 min) and appeared attributable, in part, to difficulty with the encoding and consolidation of story content.

Effect of prefrontal cortex damage on resolving lexical ambiguity in text.

The function of suppression of context-inappropriate meanings during lexical ambiguity resolution was examined in 25 adults with prefrontal cortex damage (PFCD) localized to the left (N=8), right (N=6), or bilaterally (N=11); and 21 matched Controls. Results revealed unexpected inverse patterns of suppression between PFCD and Control groups, with measures suggesting decreased interference across time in the PFCD group and increased interference in the Control group. The PFCD group, however, had significantly lower accuracy rates for the context-inappropriate condition. Results suggest a loss of the control aspects of inhibitory processes in lexical ambiguity resolution following PFCD. An aging effect on suppression function is also suggested.

Attention training for reading impairment in mild aphasia: a follow-up study.

Non-linguistic cognitive skills have recently become an area of focus in aphasia research. One skill that has received in-depth investigation is the role of attention in language tasks. In applying the resource allocation theory to aphasic language deficits, researchers have described performance variablity in language tasks that may result from insufficient capacity, inefficient allocation, or inappropriate allocation of attentional resources [16]. The present study was designed as a follow-up to a recent study examining direct attention training as a treatment for reading impairment in mild aphasia [3]. A treatment program was implemented to target complex attention skills for an individual with mild reading difficulties secondary to aphasia. Results revealed modest gains in reading rate and comprehension. A decrease in the variability of comprehension of longer complex reading passages was noted, suggesting a more efficient allocation of the participant's attentional resources. The positive gains noted for this individual's reading skills were felt to be the result of improvement in allocation of attentional resources rather than improvement in linguistic skills. The findings of this study add to the growing body of literature pertaining to the value of expanding assessment and treatment protocols for individuals with aphasia to include both linguistic and cognitive measures.

Linking inter- and intra-sentential processes for narrative production following traumatic brain injury: Implications for a model of discourse processing.

Some suggest that traumatic brain injury (TBI) produces dissociation between the macrolinguistic and microlinguistic levels of discourse production. This assumption is based primarily on studies that have found preserved intersentential cohesion and/or intra-sentential processing in narratives produced by these individuals. However, few studies exist, if any, that have investigated the relationship between these processes in TBI speakers who do demonstrate such microlinguistic impairments. This study investigated the relationship between impairments of intersentential cohesion and intra-sentential processing in the discourse of 15 speakers with severe TBI. The results demonstrated a significant relationship between the production of cohesive ties and instances of intra-sentential impairment that suggests that utilization of resources for adequate cohesion appears to negatively affect intra-sentential processing following TBI. We propose that macrolinguistic and microlinguistic processes are not independent of one another, as has been proposed, but share cognitive resources that support the planning and production of both local (microlinguistic) and long-distance (macrolinguistic) relationships expressed through discourse.

Referential cohesion and logical coherence of narration after closed head injury.

A group with closed head injury was compared to neurologically intact controls regarding the referential cohesion and logical coherence of narrative production. A sample of six stories was obtained with tasks of cartoon-elicited story-telling and auditory-oral retelling. We found deficits in the clinical group with respect to referential cohesion, logical coherence, and accuracy of narration. The occurrence of deficits depended on the condition of narrative production and, to some extent, on the particular story used. The primary implications of this study pertain to the attention given by researchers to the feature of discourse production being studied and processing demands of the task.

Acoustic analysis of parkinsonian speech I: speech characteristics and L-Dopa therapy.

This paper reviews the literature pertaining to Parkinson's disease (PD) and the speech dysfunction typically associated with PD, including the effects on respiration, phonation, articulation, resonance, and prosody. The effect of treatment with the drug L-Dopa is also examined, along with the effect of L-Dopa treatment on Parkinsonian speech. This paper is the first of a two-part series. Part two examines the literature pertaining to the fluctuations that can occur during treatment with L-Dopa, the speech changes associated with these fluctuations, and methodological issues affecting the examination of fluctuations and PD speech.

Acoustic analysis of parkinsonian speech II: L-Dopa related fluctuations and methodological issues.

The drug L-Dopa is used in the treatment of Parkinson's disease (PD), and patients often experience fluctuations in performance after a period of time taking L-Dopa. This paper reviews the literature pertaining to these fluctuations. While a number of researchers have examined L-Dopa related fluctuations in general, these fluctuations have rarely been addressed in speech research. To examine the effect of L-Dopa related fluctuations a number of methodological issues need to be addressed including time of day, anxiety level, disease stage, and drug regimen differences. Strategies are proposed for addressing these methodological issues in studying the effects of L-Dopa fluctuations on PD speech. This paper is part two of a two part series; Part one examined PD and PD speech in general, along with L-Dopa treatment, and the effects of L-Dopa treatment on speech.

Story narratives of adults with closed head injury and non-brain-injured adults: influence of socioeconomic status, elicitation task, and executive functioning.

Narratives were elicited in two story tasks, retelling and generation, from two groups of adults, 55 with closed head injury (CHI) and 47 non-brain-injured (NBI), recruited from rehabilitation facilities in three northeastern states. Participants were classified, on the basis of their socioeconomic status (SES), as professional, skilled worker, or unskilled worker. Narratives were analyzed using five discourse measures at the levels of sentence production, intersentential cohesion, and story grammar. Discourse performance was then compared across groups, tasks, and SES levels. Discourse performance of the CHI group was also compared with their scores from the Wisconsin Card Sorting Test, a measure of executive functioning. Results indicated that two discourse measures distinguished the groups. The CHI participants produced significantly fewer words per T-unit and fewer T-units within episode structure than did the NBI group, which was attributed to difficulties with content organization. Performance on all five discourse measures differed for the story retelling versus the story generation tasks for both CHI and NBI groups. All participants produced longer and more grammatically complex T-units in the story generation task than in story retelling. However, cohesive adequacy and story grammar were better in the story retelling task than in the story generation task. It was therefore concluded that story generation was a more challenging task than story retelling for both groups. The only significant difference noted for SES involved the measure of intersentential cohesion. The unskilled workers demonstrated poorer cohesive adequacy than either the skilled workers or professionals, regardless of group or story task. Finally, modest correlations were noted between the discourse performance of the CHI group and scores from the Wisconsin Card Sorting Test in both story tasks.