Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis.

BACKGROUND: Stroke rehabilitation interventions are routinely personalized to address individuals' needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias. AIM: We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database. METHODS: MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/> 65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes' median value), chronicity (⩽/> 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (> 50%), results were reported for completeness. RESULTS: 959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension > 9 h/week); older participants' greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (> 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those > 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-h/week; ⩾ 50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild-moderate participants' greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males' greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (> 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (< 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT > 9 h over ⩾ 4 days/week. CONCLUSIONS: We observed a treatment response in most subgroups' overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.

RELEASE: a protocol for a systematic review based, individual participant data, meta- and network meta-analysis, of complex speech-language therapy interventions for stroke-related aphasia.

Background: Speech and language therapy (SLT) benefits people with aphasia following stroke. Group level summary statistics from randomised controlled trials hinder exploration of highly complex SLT interventions and a clinically relevant heterogeneous population. Creating a database of individual participant data (IPD) for people with aphasia aims to allow exploration of individual and therapy-related predictors of recovery and prognosis. Aim: To explore the contribution that individual participant characteristics (including stroke and aphasia profiles) and SLT intervention components make to language recovery following stroke. Methods and procedures: We will identify eligible IPD datasets (including randomised controlled trials, non-randomised comparison studies, observational studies and registries) and invite their contribution to the database. Where possible, we will use meta- and network meta-analysis to explore language performance after stroke and predictors of recovery as it relates to participants who had no SLT, historical SLT or SLT in the primary research study. We will also examine the components of effective SLT interventions. Outcomes and results: Outcomes include changes in measures of functional communication, overall severity of language impairment, auditory comprehension, spoken language (including naming), reading and writing from baseline. Data captured on assessment tools will be collated and transformed to a standardised measure for each of the outcome domains. Conclusion: Our planned systematic-review-based IPD meta- and network meta-analysis is a large scale, international, multidisciplinary and methodologically complex endeavour. It will enable hypotheses to be generated and tested to optimise and inform development of interventions for people with aphasia after stroke. Systematic review registration: The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42018110947).

How Much Loading Does Water Resistance Voice Therapy Impose on the Vocal Folds? An Experimental Human Study.

OBJECTIVES: Water resistance voice therapy applies phonation into water through a tube. This study investigates how strenuous this therapy can be for the vocal folds in terms of impact stress (IS). It further examines whether it is possible to estimate the IS using the contact quotient (CQ) and maximum derivative from an electroglottogram (EGG). STUDY DESIGN: Experimental study. METHODS: A male participant sustained a rounded back vowel [u:] or [o:] at a comfortable speaking pitch and loudness, and phonated into a silicone "Lax Vox" tube submerged 2 cm in water. High-speed videolaryngoscopy was performed with a rigid scope. Oral air pressure (Poral) was registered in a mouthpiece through which an endoscope was inserted into the larynx. An EGG was recorded. RESULTS: The CQEGG from the EGG and the closed quotient from the glottal width (CQarea) increased, while the maximum glottal amplitude and absolute value of derivative minimum (dmin) and also the derivative maximum from the EGG decreased for phonation into water. Normalized amplitude quotient from the glottal width variation also decreased but the change was not significant. CONCLUSIONS: Based on the glottal area findings, water resistance therapy does not seem to increase vocal fold loading (in terms of increased IS) even if the increase of CQarea, and CQEGG suggest so. CQEGG may qualitatively correspond to that of area, but the reliability of CQ (from the glottal area or the EGG) and the maximum derivative from the EGG as estimates of IS in semiocclusion exercises warrant further studies.

Vocal Emotion Identification by Children Using Cochlear Implants, Relations to Voice Quality, and Musical Interests.

Purpose: Listening tests for emotion identification were conducted with 8-17-year-old children with hearing impairment (HI; N = 25) using cochlear implants, and their 12-year-old peers with normal hearing (N = 18). The study examined the impact of musical interests and acoustics of the stimuli on correct emotion identification. Method: The children completed a questionnaire with their background information and noting musical interests. They then listened to vocal stimuli produced by actors (N = 5) and consisting of nonsense sentences and prolonged vowels ([a:], [i:], and [u:]; N = 32) expressing excitement, anger, contentment, and fear. The children's task was to identify the emotions they heard in the sample by choosing from the provided options. Acoustics of the samples were studied using Praat software, and statistics were examined using SPSS 24 software. Results: The children with HI identified the emotions with 57% accuracy and the normal hearing children with 75% accuracy. Female listeners were more accurate than male listeners in both groups. Those who were implanted before age of 3 years identified emotions more accurately than others (p < .05). No connection between the child's audiogram and correct identification was observed. Musical interests and voice quality parameters were found to be related to correct identification. Conclusions: Implantation age, musical interests, and voice quality tended to have an impact on correct emotion identification. Thus, in developing the cochlear implants, it may be worth paying attention to the acoustic structures of vocal emotional expressions, especially the formant frequency of F3. Supporting the musical interests of children with HI may help their emotional development and improve their social lives.