Rehabilitation of Swallowing and Cough Functions Following Stroke: An Expiratory Muscle Strength Training Trial.

OBJECTIVE: To determine the effect of expiratory muscle strength training (EMST) on both cough and swallow function in stroke patients. DESIGN: Prospective pre-post intervention trial with 1 participant group. SETTING: Two outpatient rehabilitation clinics. PARTICIPANTS: Adults (N=14) with a history of ischemic stroke in the preceding 3 to 24 months. INTERVENTION: EMST. The training program was completed at home and consisted of 25 repetitions per day, 5 days per week, for 5 weeks. MAIN OUTCOME MEASURES: Baseline and posttraining measures were maximum expiratory pressure, voluntary cough airflows, reflex cough challenge to 200µmol/L of capsaicin, sensory perception of urge to cough, and fluoroscopic swallow evaluation. Repeated measures and 1-way analyses of variance were used to determine significant differences pre- and posttraining. RESULTS: Maximum expiratory pressure increased in all participants by an average of 30cmH2O posttraining. At baseline, all participants demonstrated a blunted reflex cough response to 200µmol/L of capsaicin. After 5 weeks of training, measures of urge to cough and cough effectiveness increased for reflex cough; however, voluntary cough effectiveness did not increase. Swallow function was minimally impaired at baseline, and there were no significant changes in the measures of swallow function posttraining. CONCLUSIONS: EMST improves expiratory muscle strength, reflex cough strength, and urge to cough. Voluntary cough and swallow measures were not significantly different posttraining. It may be that stroke patients benefit from the training for upregulation of reflex cough and thus improved airway protection.

Measurement of Voluntary Cough Production and Airway Protection in Parkinson Disease.

OBJECTIVE: To examine relations between peak expiratory (cough) airflow rate and swallowing symptom severity in participants with Parkinson disease (PD). DESIGN: Cross-sectional study. SETTING: Outpatient radiology clinic at an acute care hospital. PARTICIPANTS: Men and women with PD (N=68). INTERVENTIONS: Participants were cued to cough into an analog peak flow meter then swallowed three 20-mL thin liquid barium boluses. Analyses were directed at detecting potential relations among disease severity, swallowing symptom severity, and peak expiratory (cough) airflow rate. MAIN OUTCOME MEASURES: Peak expiratory (cough) airflow rate and swallow symptom severity. RESULTS: Peak expiratory (cough) airflow rate varied significantly across swallowing severity classifications. Participants with more severe disease displayed a significant, linear decrease in peak expiratory (cough) airflow rate than those participants with earlier stage, less severe disease. Swallowing symptom severity varied significantly across groups when comparing participants with less severe PD with those with more severe PD. Participants with early stage PD demonstrated little to no swallowing symptoms and had the highest measures of peak expiratory (cough) airflow rate. In contrast, participants with the most severe swallowing symptoms also displayed the lowest measures of peak expiratory (cough) airflow rate. CONCLUSIONS: Relations existed among PD severity, swallowing symptom severity, and peak expiratory (cough) airflow rate in participants with PD. Peak expiratory (cough) airflow rate may eventually stand as a noninvasive predictor of aspiration risk in those with PD, particularly those with later stage disease. Inclusion of peak expiratory (cough) airflow rates into existing clinical swallowing assessments may increase the sensitivity and predictive validity of these assessments.

Conceptualizing functional cognition in traumatic brain injury rehabilitation.

PRIMARY OBJECTIVE: To conceptualize functional cognitive constructs across the continuum of traumatic brain injury (TBI) recovery, to form the foundation for the Computer Adaptive Measure of Functional Cognition for TBI (CAMFC-TBI). BACKGROUND: TBI often has a profound impact on a survivor's ability to return to previous level of functioning and significantly reduces the overall quality of life for survivors and caregivers. Few assessments are designed to evaluate TBI's impact on cognitive functioning in everyday life. Neuropsychological tests are time consuming and may have questionable ecological validity for predicting functional outcomes. Global functional assessments contain few cognitive items and may lack psychometric rigour. Presently there is a lack of efficient, precise, ecologically valid functional cognitive measures. MAIN OUTCOME AND RESULTS: Studies that used neuropsychological and global functional assessments were reviewed to direct conceptualization of functional cognitive constructs across TBI recovery stages. An advisory panel reviewed study methodology and functional cognitive constructs development. They validated the need for the CAMFC-TBI and the six functional cognitive constructs: attention, memory, processing speed, executive functioning, social communication and emotional management. CONCLUSION: Conceptualizing functional cognitive constructs is the first step in CAMFC-TBI development. Future project stages include item pool development, qualitative testing, field-testing, psychometric analysis and computerized adaptive test programming.

Dosing of a cued picture-naming treatment for anomia.

PURPOSE: Recent investigations into effects of intensity or distribution of aphasia therapy have provided moderate evidence supporting intensive therapy schedules on aphasia treatment response. The purpose of the present study was to investigate the feasibility of creating an intensive therapy session without extending the amount of daily time a person spends in treatment. METHOD: Individuals who presented with chronic anomia poststroke (N = 8) participated in 2 weeks of a computerized, therapist-delivered, cued, picture-naming treatment. Dosing parameters for each session were 8 presentations of 50 pictures, totaling 400 teaching episodes per session. RESULTS: Of the 8 participants, 6 achieved significant increases from baseline on trained items after 400 teaching episodes (i.e., 1 treatment hr), and the remaining 2 participants achieved significant increases from baseline after 1200 teaching episodes (i.e., 3 treatment hr). Maintenance data from 7 of the participants indicated that 6 participants maintained significant improvement from baseline on trained items. CONCLUSIONS: Given an intensive and saturated context, anomic individuals were surprisingly quick at relearning to produce problematic words successfully. Most participants demonstrated retention of the gains 2 months after treatment ended. The high density of teaching episodes within the treatment session (i.e., the intensive treatment schedule) may have contributed to the behavioral gains.

Exploration of patient-centered success criteria and clinically measured improvement during falls rehabilitation.

BACKGROUND AND PURPOSE: One method for defining successful rehabilitation outcomes is to use a threshold of performance on a clinical measure. Patients also have their own criteria for success. The aim of this study was to examine the association between clinical measures and patient criteria for determining successful intervention. METHODS: Twenty-two participants participated in a 12-week intervention program for balance disorders. Participants were tested using the Berg balance scale (BBS) and dynamic gait index (DGI) at the first and final visits. They also used the patient's perspective outcomes questionnaire (PPOQ) at the first visit to rate impairments in the core domains from the international classification of Function. Participants rated their usual levels of impairment across domains, their desired levels of impairment after intervention (success criteria), and how important it was to change in each domain. At the final visit, all participants used the PPOQ to rate their current impairment across domains and completed a 15-point global rating of change (GRC). The intervention was defined as a success if the participant rated himself or herself as "a great deal" or "a very great deal" better using the GRC. Changes in the BBS and the DGI were dichotomized on the basis of whether the change exceeded the minimal detectable change (MDC) of the instrument. Participants' ratings of impairment at 12 weeks were compared with their success criteria and dichotomized on the basis of whether the success criteria had been met. The Freidman test was used to test differences across domains at baseline with Wilcoxon tests for follow-up. Wilcoxon tests were also used to examine the importance of change across domains. Chi-square tests were used to explore the association among the GRC, performance on clinical tests, and whether success criteria were met. RESULTS: Significant changes were noted for the group for both BBS (P < .001) and DGI (P = .006). Only 40% of participants exceeded or met their desired or expected change in impairment for mobility. No significant associations were noted between exceeding MDC on the BBS or DGI and any of the domains on the PPOQ (all Ps = .263). Bivariate associations were noted between baseline measures of psychological factors and many of the participant ratings of impairment. Fifty-five percent of participants indicated that they were a great deal better or a very great deal better. Significant association was identified between success and exceeding MDC on the BBS (χ = 5.84, P = .016) but not the DGI. When considering participants' desired change in impairment, only meeting desired changes in mental function was associated with considering the intervention a success (χ = 4.55, P = .033). DISCUSSION: Treatment success from the perspective of this group of older adults was related to improvement on a clinic-based performance measure and not the participants' intrinsic success criteria assessed at the beginning of the intervention. CONCLUSION: Making measurable change in gait and balance translates into perceived success for the patient with a balance disorder.

Treatment of word-finding deficits in fluent aphasia through the manipulation of spatial attention: Preliminary findings.

BACKGROUND: Attention, the processing of one source of information to the exclusion of others, is important for most cognitive processes, including language. Evidence suggests not only that dysfunctional attention mechanisms contribute to language deficits after stroke, but also that orienting attention to a patient's ipsilesional hemispace recruits attention mechanisms in the intact hemisphere and improves language functions in some persons with aphasia. AIMS: The aim of the current research was to offer proof of concept for the strategy of improving picture-naming performance in fluent aphasia by moving stimuli into the left hemispace. It was hypothesised that repeated orientation of attention to the ipsilesional hemispace during picture naming would lead to improved naming accuracy for participants with fluent aphasia. METHODS #ENTITYSTARTX00026; PROCEDURES: Three participants with stable fluent aphasia received daily treatment sessions that consisted of naming simple line drawings presented 45 degrees to the left of body midline on a computer monitor. Naming probes were administered before initiation of the treatment protocol to establish a baseline, and before each treatment session to measure change during treatment. The C statistic was used to establish the stability of baseline performance and to determine whether the slope of the treatment phases differed significantly from the slope of the baseline. OUTCOMES #ENTITYSTARTX00026; RESULTS: Two of the three participants showed significant improvement over baseline performance in the percent correct of naming probes. One participant showed no improvement over baseline accuracy. CONCLUSIONS: Results suggest that engaging right-hemisphere attention mechanisms may improve naming accuracy in some people with fluent aphasia. Findings justify further investigation of this treatment in a larger controlled study.

Semantic-phonologic treatment for noun and verb retrieval impairments in aphasia.

Nouns and verbs differ in their neural and psycholinguistic attributes. It is not known whether these differences lead to distinct patterns of response to treatment for individuals with word retrieval impairments associated with aphasia. Eight participants with naming disorders induced by left hemisphere strokes were treated with a semantic-phonologic treatment protocol for nouns and verbs using a single participant multiple baseline design. We measured treatment gains in a picture naming measure and other secondary language and communication measures. Treatment led to improved picture naming for trained nouns and verbs in five of eight patients, with no difference evident between nouns and verbs. Improvements for untrained words were minimal. Improvement in verb retrieval was associated with increases on a functional measure of communicative effectiveness. Improvement for nouns and verbs was associated with severity of word retrieval impairment at onset. Although distinct in neural and psycholinguistic attributes, nouns and verbs were affected by treatment in a similar pattern in this group of individuals. Training-specific effects suggest the need for careful selection of training words to have potential for functional benefit in daily communication.

Treatment of naming in nonfluent aphasia through manipulation of intention and attention: a phase 1 comparison of two novel treatments.

Twenty-three chronic nonfluent aphasia patients with moderate or severe word-finding impairments and 11 with profound word-finding impairments received two novel picture-naming treatments. The intention treatment initiated picture-naming trials with a complex left-hand movement and was designed to enhance right frontal participation during word retrieval. The attention treatment required patients to view visual stimuli for picture-naming trials in their left hemispace and was designed to enhance right posterior perisylvian participation during word retrieval. Because the intention treatment addressed action mechanisms and nonfluent aphasia reflects difficulty initiating or maintaining action (i.e., language output), it was hypothesized that intention component of the treatment would enhance re-acquisition of picture naming more than the attention component. Patients with moderate and severe word-finding impairment showed gains with both treatments but greater incremental improvement from one treatment phase to the next with the intention than the attention treatment. Thus, the hypothesis that intention component would be a more active constituent than the attention component was confirmed for these patients. Patients with profound word-finding impairment showed some improvement with both treatments but no differential effects for the intention treatment. Almost all patients who showed treatment gains on either treatment also demonstrated generalization from trained to untrained items.

Effects of gesture+verbal treatment for noun and verb retrieval in aphasia.

Links between verbs and gesture knowledge suggest that verb retrieval may be particularly amenable to gesture+verbal training (GVT) in aphasia compared to noun retrieval. This study examines effects of GVT for noun and verb retrieval in nine individuals with aphasia subsequent to left hemisphere stroke. Participants presented an array of noun and verb retrieval deficits, including impairments of semantic and/or phonologic processing. In a single-participant experimental design, we investigated effects of GVT for noun and verb retrieval in two counterbalanced treatment phases. Effects were evaluated in spoken naming and gesture production to pictured objects and actions. Spoken naming improvements associated with large effect sizes were noted for trained nouns (5/9) and verbs (5/9); no improvements were evident for untrained words. Gesture production improved for trained nouns (8/9) and verbs (6/9), and for untrained nouns (2/9) and verbs (2/9). No significant differences were evident between nouns and verbs in spoken naming or gesture production. Improvements were evident across individuals with varied sources of word retrieval impairments. GVT has the potential to improve communication by increasing spoken word retrieval of trained nouns and verbs and by promoting use of gesture as a means to communicate when word retrieval fails.

Effects of two treatments for aprosodia secondary to acquired brain injury.

Expressive aprosodia is an impaired ability to change one's voice to express common emotions such as joy, anger, and sadness. Individuals with aprosodia speak in a flat, unemotional voice that often results in miscommunicated emotional messages. This study investigated two conceptually based treatments for expressive aprosodia: imitative treatment and cognitive-linguistic treatment. Five women and nine men with expressive aprosodia following right-hemisphere brain damage received the treatments in two phases 1 month apart in random order. Treatment was received 3 to 4 days a week for a total of 20 sessions each phase. As the outcome measure, sentences that elicited treated (happy, angry, sad, neutral) and untreated (fear) emotional tones of voice were administered during baseline, prior to treatment sessions, following treatment termination, and at 1- and 3-month follow-ups. Effect sizes indicated that treatment effects were modest to substantial and that 12 participants responded to at least one treatment. Four responsive participants who were available for follow-up showed benefit at 1 and 3 months posttreatment. Most visual and statistical analyses were congruent.

Neural substrates of syntactic mapping treatment: an fMRI study of two cases.

Two patients (G01, J02) with chronic nonfluent aphasia and sentence production deficits received syntactic mapping treatment to improve sentence production. The patients had dramatically different outcomes in that improved syntax production generalized to nontreatment tasks for G01, but not for JO2. To learn how treatment influenced the neural substrates for syntax production, both patients underwent pre- and posttreatment functional magnetic resonance imaging (fMRI) of sentence generation. G01 showed more robust activity posttreatment than pretreatment in Broca's area; ventral temporal activity decreased slightly from pre- to posttreatment. Comparison of J02's pretreatment and posttreatment images revealed little change, although activity was more diffuse pre- than posttreatment. Findings suggest that for G01, rehabilitation led to engagement of an area (Broca's area) used minimally during the pretreatment scan, whereas for J02, rehabilitation may have led to more efficient use of areas already involved in sentence generation during the pretreatment scan. fMRI findings are discussed in the context of sentence-production outcome and generalization.

Activation of intentional mechanisms through utilization of nonsymbolic movements in aphasia rehabilitation.

Intentional mechanisms play an important role in complex self-initiated actions, such as language and gesturing. Deficits demonstrated in nonfluent aphasia may be a result of a disconnection between or damage to the initiation (intention) and production mechanisms in the left hemisphere. In chronic nonfluent aphasias, damaged language production mechanisms in the left hemisphere may switch to homologous regions in the right hemisphere while the initiation mechanisms remain active in the left hemisphere. A treatment was developed to prime right-hemisphere initiation mechanisms with movements of the nondominant hand, thereby bringing initiation into the right hemisphere where the language production mechanisms have been shifted. Three subjects with stable, chronic nonfluent aphasias were trained in daily sessions with a therapist to perform a complex nonsymbolic movement sequence with their nondominant hand to initiate naming trials of simple line drawings. Naming probes were administered during pre treatment baseline sessions and before each treatment session. All three subjects demonstrated a stable baseline and a significant increase over baseline performance in the percentage correct on naming probes during the treatment. Findings indicate that more extensive investigations of this newly developed treatment are justified and suggest that activation of right-hemisphere initiation mechanisms may enhance word production accuracy in stable, chronic nonfluent aphasias.