Incidence of Aphasia in Ischemic Stroke.

INTRODUCTION: A decrease in ischemic stroke (IS) incidence has been observed in high income countries during the last decades. Whether this has influenced the occurrence of aphasia in IS is uncertain. We therefore examined the incidence rate and potentially related determinants of aphasia in IS. METHODS: We prospectively examined consecutive patients admitted to hospital with first-ever acute IS between March 1, 2017, and February 28, 2018, as part of the Lund Stroke Register (LSR) Study, comprising patients from the uptake area of Skåne University Hospital, Lund, Sweden. Patients were assessed with National Institutes of Health Stroke Scale (NIHSS) at stroke onset. Presence of aphasia was evaluated with NIHSS item 9 (language). We registered IS subtypes and risk factors. To investigate possible temporal changes in aphasia incidence, we made comparisons with corresponding LSR data from 2005 to 2006. Incidence rates were calculated and adjusted to the European Standard Population (ESP) and to the Swedish population. RESULTS: Among 308 included IS patients, 30% presented with aphasia (n = 91; 95% CI: 25-35), a proportion of aphasia in IS that was similar to 2005-2006. The incidence rate of aphasia was 31 per 100,000 person-years adjusted to the ESP (95% CI: 25-38 per 100,000 person-years) corresponding to a significant decrease of 30% between 2005-2006 and 2017-2018. The decrease was significantly more pronounced in men. The initial severity of aphasia remained unchanged, with the majority of patients having severe to global aphasia. No significant differences between vascular stroke risk factors were noted among stroke patients with or without aphasia. CONCLUSION: Even though the overall IS incidence rate has decreased during the first decades of the 21st century, the proportion of IS patients with aphasia at stroke onset remains stable at 30%. Aphasia continues to be an important symptom that needs to be considered in stroke care and rehabilitation.

Using a digital spelling aid to improve writing in persons with post-stroke aphasia: An intervention study.

BACKGROUND: Intervention studies aimed to improve the written production of single words by persons with aphasia have yielded promising results and there is growing interest in interventions targeting text writing. The development of technical writing aids offers opportunities for persons with aphasia, and studies have shown that using them can have a positive impact on written output. AIMS: The aim was to investigate what impact training to use a computerised spell checker had on text writing in persons with aphasia. METHODS & PROCEDURES: The study had a multiple-baseline single-case experimental design replicated across six male Swedish participants with mild-to-moderate post-stroke aphasia. The participants received training twice a week during 8 weeks, learning how to use the spell checker. At baseline and before every session, the participants wrote two texts which were logged in a keystroke-logging tool. Dependent variables were continuously measured in the texts, and the participants performed tests of language function and answered questionnaires on reading and writing habits and health-related quality of life before and after the intervention. The participants were also interviewed about how they had experienced the training. The results were evaluated on individual and group level. RESULTS: The study showed that systematic individual training involving a spell checker was experienced as positive by the participants and that they all described their writing ability in more positive terms after the intervention. Evaluation showed statistically significant improvements on group level for the dependent variables of spelling accuracy, rated syntax, writing speed and proportion of unedited text during text writing when using the spell checker. The intervention also had a generalising effect on writing speed and editing during text writing without the spell checker and on spelling accuracy in a dictation test. The participants who had the greatest spelling problems were the ones who showed the most progress, but participants with only minor writing difficulties at baseline also improved. CONCLUSIONS & IMPLICATIONS: The study shows that a digital spelling aid constitutes effective support for people with aphasia and may also affect levels other than spelling. The training had a generalising positive effect on text writing and spelling in a test. Although writing difficulties is a persisting symptom in aphasia, it can be supported and improved through use of digital spelling aids. Hence, treatment of writing ability should always be included in the rehabilitation of people with aphasia. WHAT THIS PAPER ADDS: What is already known on this subject Use of a technical writing aid can have a positive impact on the written output of persons with aphasia. Using a digital spell checker may improve spelling as well as other levels of writing, but it has not been investigated using a keystroke-logging tool in combination with language-test scores and results from questionnaires. What this paper adds to existing knowledge Through analyses on both individual and group level, this study shows that a digital spelling aid constitutes effective support for people with aphasia and also affects levels other than spelling. The training had a generalising positive effect on text writing and spelling in a test. What are the potential or actual clinical implications of this work? Digital spelling support, which is a relatively simple and inexpensive technology, can support and improve text writing in persons with post-stroke aphasia.

Accuracy of NIH Stroke Scale for diagnosing aphasia.

OBJECTIVES: The National Institutes of Health Stroke Scale (NIHSS) has not been validated to diagnose aphasia in the stroke population. We therefore examined the diagnostic accuracy of NIHSS for detecting aphasia in acute ischemic stroke. METHODS: Consecutive patients with acute first-ever ischemic stroke were included prospectively in Lund Stroke Register Study at Skåne University Hospital, Sweden. Exclusion criteria were: (a) non-native Swedish; (b) obtundation (c) dementia or psychiatric diagnosis. Patients were assessed with NIHSS item 9 (range 0-3, where 1-3 indicate aphasia) by a NIHSS certified research nurse in the acute phase after stroke onset (median 3 days). Within 24 h after this assessment, a speech therapist evaluated the patients' language function with the comprehensive language screening test (LAST, range 0-15 where 0-14 indicates aphasia). Data were analyzed using LAST as 'reference standard'. RESULTS: We examined 221 patients. Among these, 23% (n = 50) had aphasia according to NIHSS (distribution of scores 0, 1, 2, 3 were n = 171, n = 29, n = 12, n = 9) compared to 26% (n = 58) with aphasia according to LAST (score ≤14; median = 11). Assuming LAST as reference standard, NIHSS gave 16 false negatives (NIHSS item 9 = 0) for aphasia (LAST scores range 8-14), and 8 false positives (NIHSS item 9 score = 1) for aphasia, yielding a sensitivity of 72% (0.59-0.83) and a specificity of 95% (0.91-0.98). CONCLUSIONS: When using NIHSS for screening and diagnosing aphasia in adults with acute ischemic stroke, patients with severe aphasia can be detected, however, some mild aphasias might be misclassified. Given the 72% sensitivity, absence of aphasia on the NIHSS should not be used to guide stroke treatment.

Aphasia and spelling to dictation: Analysis of spelling errors and editing.

INTRODUCTION: Spelling difficulty is a common symptom of aphasia and can entail editing difficulties. Previous research has shown that extensive editing is related to a lower production rate in text writing for persons with aphasia, yet editing difficulty is not commonly examined. It is not known if editing difficulty is related to reading and writing skills or to aspects of the word. AIMS: To analyse spelling and editing processes as well as errors in a dictation task performed by Swedish-speaking adults with post-stroke aphasia. Furthermore, the study aimed to identify any relationships between spelling and editing difficulties and characteristics of individual words. Finally, relationships between successful edits and reading and phonological ability were investigated and specific editing strategies or behaviours identified. Correlation analyses were performed between measures of spelling and editing and word frequency and length as well as participants' scores on tests of reading, phonological spelling and phonological decoding. METHODS & PROCEDURES: A total of 16 Swedish speaking participants with post-stroke aphasia wrote a word-dictation task in a keystroke logging program and were tested for phonological spelling, phonological decoding and reading ability. Spelling errors were categorized and analysed. OUTCOMES & RESULTS: The most common error type was omission of letter(s) and there was evidence of aphasia-specific writing errors. Both spelling and editing difficulty were related to word frequency and word length. Successful editing was related to participants' scores on the phonological spelling task, but not to phonological decoding or reading ability. Specific editing strategies could be identified, and some strategies were individual, while others were more commonly used. CONCLUSIONS & IMPLICATIONS: Word length and word frequency should be taken into consideration in spelling tests for persons with aphasia, and the presence of editing difficulty should be taken into account when assessing spelling difficulties. Treatment for writing difficulties in aphasia should include training in successful editing strategies and individual fitting of digital writing aids. What this paper adds What is already known on the subject Post-stroke aphasia often causes writing and spelling difficulties. Spelling difficulties may entail editing difficulties, in turn causing extensive and/or unsuccessful editing. Extensive editing is known to impede productivity in text writing. Still, editing behaviour, abilities relating to editing or what features of a word that causes editing difficulty has not been investigated for persons with aphasia. What this paper adds to existing knowledge This study adds an in-depth analysis of spelling ability, spelling errors and editing behaviour for persons with aphasia, using keystroke logging and a single-word dictation task. Results showed that both features of the target word (frequency and word length) and the individual abilities of the person with aphasia (score on a phonological spelling task) related to spelling and editing difficulty, editing behaviour and successful editing. Specific editing strategies were analysed and described. What are the potential or actual clinical implications of this work? Word length and word frequency should be taken into consideration when testing single-word spelling for persons with aphasia. When assessing spelling difficulties, both correctness of spelling as well as the presence and nature of any editing difficulties should be taken into account and treatment for writing difficulties in should include training in successful editing strategies. The fitting of digital writing aids for persons with aphasia should be individual, since many of the editing strategies used were individual.

Book talk and aphasia: the power of a book.

BACKGROUND: Reading is most often affected in aphasia and this has an impact on most aspects of everyday life. Being able to read makes a significant difference to how well a person can participate in society. In this study, people with aphasia recount their experiences of being in a book club. AIMS: This small scale, exploratory study employs a qualitative approach to investigate how persons with aphasia (PWA) and a librarian experience participating in a book club. The aim was to explore their overall experiences of participation, including their views regarding the design of the book club. The research questions were: How did participants experience participating in a book club? How did participants experience the structure and the content of the book club? METHODS & PROCEDURES: Three men and one woman with aphasia took part in a book club, which was led by a librarian and met once a week for 9 weeks. The group read a book that had been adapted to suit adults who are not very skilled readers or who have a poor knowledge of the Swedish language; it was also available in an audio version. Data were collected through observations, interviews and field notes, and were analysed thematically to find patterns across data and across participants. OUTCOMES & RESULTS: The analysis showed that, despite their language difficulties, the participants experienced the book club as highly rewarding, possibly because the focus was on the content of the book and not on each individual's reading ability. The overarching theme identified in the data was 'Empowerment through a joint reading experience'. This encompassed three sub-themes: 'Structure and flexibility', 'Enjoyment of reading' and 'Fruitful discussions'. CONCLUSIONS & IMPLICATIONS: The PWA experienced the activity as positive and encouraging despite their language difficulties. What yielded the positive experience were the joint literary discussions. The project also showed that a dedicated group leader (here the librarian) and a flexible structure based on the situation and abilities of each individual were crucial for the encouraging findings.

Writing fluency in patients with low-grade glioma before and after surgery.

BACKGROUND: Low-grade glioma (LGG) is a type of brain tumour often situated in or near areas involved in language, sensory or motor functions. Depending on localization and tumour characteristics, language or cognitive impairments due to tumour growth and/or surgical resection are obvious risks. One task that may be at risk is writing, both because it requires intact language and memory function and because it is a very complex and cognitively demanding task. The most commonly reported language deficit in LGG patients is oral lexical-retrieval difficulties, and poor lexical retrieval would be expected to affect writing fluency. AIMS: To explore whether writing fluency is affected in LGG patients before and after surgery and whether it is related to performance on tasks of oral lexical retrieval. METHODS & PROCEDURES: Twenty consecutive patients with presumed LGG wrote a narrative and performed a copy task before undergoing surgery and at 3-month follow-up using keystroke-logging software. The same tasks were performed by a reference group (N = 31). The patients were also tested using the Boston Naming Test (BNT) and word-fluency tests before and after surgery. Writing fluency was compared between the patients and the reference group, and between the patients before and after surgery. Relationships between performance on tests of oral lexical retrieval and writing fluency were investigated both before and after surgery. OUTCOME & RESULTS: Different aspects of writing fluency were affected in the LGG patients both before and after surgery. However, when controlling for the effect of typing speed, the LGG group differed significantly from the reference group only in the proportion of pauses within words. After surgery, a significant decline was seen in production rate and typing speed in the narrative task, and a significant increase was seen in pauses before words. Strong positive relationships were found between oral lexical retrieval and writing fluency both before and after surgery. CONCLUSIONS & IMPLICATIONS: Although aspects of writing fluency were affected both before and after surgery, the results indicate that typing speed is an important factor behind the pre-surgery differences. However, the decline in overall productivity and the increase in pauses before words after surgery could be related to a lexical deficit. This is supported by the finding that oral lexical-retrieval scores were strongly correlated with writing fluency. However, further exploration is needed to identify the language and cognitive abilities affecting writing processes in LGG patients.

Aphasia and literacy-the insider's perspective.

BACKGROUND: Few studies have investigated how people with aphasia (PWA) experience literacy skills. Taking the insider's perspective is a way to increase understanding of the individual experiences of literacy among PWA, which may have clinical implications. AIMS: To describe how literacy, i.e., reading and writing, is experienced in everyday life by PWA and to gain insight into the part played by literacy skills in their lives. METHODS & PROCEDURES: A qualitative descriptive research approach was taken. In-depth interviews were conducted with 12 PWA (six women and six men) who had all lived with aphasia for at least 6 months post-stroke. The interviews were analysed using qualitative content analysis. OUTCOMES & RESULTS: One overarching theme emerged from the data: literacy as an ongoing recovery process. Based on this overarching theme, two subthemes were identified: changes in conditions for literacy (experiences of reading and writing initially post-onset compared with experiences at the time of the interview); and facing expectations about literacy (participants' own and other people's expectations of them in terms of literacy). CONCLUSIONS & IMPLICATIONS: The findings are important at a general level in that they indicate that PWA are able to articulate their individual experiences and thoughts about literacy, i.e., reading and writing. Specifically, PWA in this study experience literacy as playing an essential part in their lives and the findings imply that personal experiences are important in the design of reading and writing interventions in speech and language therapy.