Change in Right Inferior Longitudinal Fasciculus Integrity Is Associated With Naming Recovery in Subacute Poststroke Aphasia.

Background. Despite progress made in understanding functional reorganization patterns underlying recovery in subacute aphasia, the relation between recovery and changes in white matter structure remains unclear. Objective. To investigate changes in dorsal and ventral language white matter tract integrity in relation to naming recovery in subacute poststroke aphasia. Methods. Ten participants with aphasia after left-hemisphere stroke underwent language testing and diffusion tensor imaging twice within 3 months post onset, with a 1-month interval between sessions. Deterministic tractography was used to bilaterally reconstruct the superior longitudinal fasciculus (SLF), inferior fronto-occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), middle longitudinal fasciculus (MdLF), and uncinate fasciculus (UF). Per tract, the mean fractional anisotropy (FA) was extracted as a measure of microstructural integrity. Naming accuracy was assessed with the Boston Naming Test (BNT). Correlational analyses were performed to investigate the relationship between changes in FA values and change in BNT score. Results. A strong positive correlation was found between FA change in the right ILF within the ventral stream and change on the BNT (r = 0.91, P < .001). An increase in FA in the right ILF was associated with considerable improvement of naming accuracy (range BNT change score: 12-14), a reduction with limited improvement or slight deterioration. No significant correlations were found between change in naming accuracy and FA change in any of the other right or left ventral and dorsal language tracts. Conclusions. Naming recovery in subacute aphasia is associated with change in the integrity of the right ILF.

Validation of a prediction model for long-term outcome of aphasia after stroke.

BACKGROUND: About 30% of stroke patients suffer from aphasia. As aphasia strongly affects daily life, most patients request a prediction of outcome of their language function. Prognostic models provide predictions of outcome, but external validation is essential before models can be used in clinical practice. We aim to externally validate the prognostic model from the Sequential Prognostic Evaluation of Aphasia after stroKe (SPEAK-model) for predicting the long-term outcome of aphasia caused by stroke. METHODS: We used data from the Rotterdam Aphasia Therapy Study - 3 (RATS-3), a multicenter RCT with inclusion criteria similar to SPEAK, an observational prospective study. Baseline assessment in SPEAK was four days after stroke and in RATS-3 eight days. Outcome of the SPEAK-model was the Aphasia Severity Rating Scale (ASRS) at 1 year, dichotomized into good (ASRS-score of 4 or 5) and poor outcome (ASRS-score < 4). In RATS-3, ASRS-scores at one year were not available, but we could use six month ASRS-scores as outcome. Model performance was assessed with calibration and discrimination. RESULTS: We included 131 stroke patients with first-ever aphasia. At six months, 86 of 124 (68%) had a good outcome, whereas the model predicted 88%. Discrimination of the model was good with an area under the receiver operation characteristic curve of 0.87 (95%CI: 0.81-0.94), but calibration was unsatisfactory. The model overestimated the probability of good outcome (calibration-in-the-large α = - 1.98) and the effect of the predictors was weaker in the validation data than in the derivation data (calibration slope ß = 0.88). We therefore recalibrated the model to predict good outcome at six months. CONCLUSION: The original model, renamed SPEAK-12, has good discriminative properties, but needs further external validation. After additional external validation, the updated SPEAK-model, SPEAK-6, may be used in daily practice to discriminate between patients with good and patients with poor outcome of aphasia at six months after stroke. TRIAL REGISTRATION: RATS-3 was registered on January 13th 2012 in the Netherlands Trial Register: NTR3271 . SPEAK was not listed in a trial registry.

ImPACT: a multifaceted implementation for conversation partner training in aphasia in Dutch rehabilitation settings.

PURPOSE: Exploration of the clinical uptake of a novel conversation partner training (CPT) programme in aphasia in 10 Dutch rehabilitation facilities and identification of its perceived facilitators and barriers in service providers, and the evaluation of the implementation methods used. METHOD: Ten rehabilitation centres took part in a multifaceted implementation of CPT over 13 months. Each centre selected two speech and language therapists to act as knowledge brokers whose role was to raise awareness of CPT in the team and to facilitate getting partners of people with aphasia into the programme. The implementation was evaluated using analysis of recruitment data and questionnaires, supplemented by consensus data and scrutiny of implementation plans. RESULTS: Successful implementation was described as (1) four dyads included during the intervention period, (2) two more dyads included after the intervention period, before the end of the study, and (3) inclusion of the Partners of Aphasic clients Conversation Training (PACT) programme in a description of the logistics of local stroke care (stroke care pathway). Seven centres were successful in reaching the target inclusion of six dyads in total. Only one centre had care pathways in place. From a recruitment pool of 504 dyads, 41 dyads were recruited and 34 partners completed the implementation study of the PACT. Observed facilitators included the motivation to engage partners in the rehabilitation process and the perceived added value of PACT. The perceived barriers focused on time limitations within current systems to discuss the consequences of PACT with relevant professionals and to establish allocated time for this training within existing care routines. CONCLUSIONS: The motivation of professionals to involve partners in the rehabilitation process assisted with the introduction of PACT in practice. The main barrier was time, linked to the requirement to think through integration of this innovation within existing care. Longer term evaluation would ascertain how centres sustain uptake without support. Implications for Rehabilitation The integration of a new treatment method that reaches beyond the boundaries of one group of professionals needs to be facilitated by providing time to all team members involved to discuss and think through the consequences of that approach for clinical decision making within the care trajectory of a client and his/her significant other. Partners of people with aphasia need to be properly informed about the collaborative nature of communication with a view to the longer term adjustment to living with someone with aphasia.

'Now it is about me having to learn something .' Partners' experiences with a Dutch conversation partner training programme (PACT).

BACKGROUND: The increase in the number of reported conversation partner programmes for conversation partners of people with aphasia demonstrates increased awareness of partner needs and the positive effect of trained partners on the communicative abilities of the person with aphasia. Predominantly small-scale studies describe the effectiveness of conversation partner training (CPT) and how partners perceive this training. The view of partners on this service commission remains largely unknown. AIMS: To explore the experiences of partners of people with aphasia with a CPT programme when it was newly introduced into rehabilitation settings. METHODS & PROCEDURES: Seventeen partners of people with aphasia were interviewed using a semi-structured format about their experience with Partners of Aphasic Clients Conversation Training (PACT). Transcribed interviews were analysed using qualitative content analysis. OUTCOMES & RESULTS: Four categories representative of the practical nature and individual tailoring of PACT were identified: engaging with PACT; learning from PACT; reflecting on behaviour and emotions; and experiences with earlier speech and language therapy (SLT). Two themes were identified cutting across all categories: the nature of communication is difficult to grasp; and balancing roles as partner, carer and client. CONCLUSIONS & IMPLICATIONS: Partners appreciated the training programme once their initial lack of awareness of the interactive nature of communication had been addressed. SLTs need to be clear about the collaborative nature of conversations and what can be offered within the rehabilitation trajectory to address conversation alongside language training.

Screening tests for aphasia in patients with stroke: a systematic review.

Aphasia has a large impact on the quality of life and adds significantly to the costs of stroke care. Early recognition of aphasia in stroke patients is important for prognostication and well-timed treatment planning. We aimed to identify available screening tests for differentiating between aphasic and non-aphasic stroke patients, and to evaluate test accuracy, reliability, and feasibility. We searched PubMed, EMbase, Web of Science, and PsycINFO for published studies on screening tests aimed at assessing aphasia in stroke patients. The reference lists of the selected articles were scanned, and several experts were contacted to detect additional references. Of each screening test, we estimated the sensitivity, specificity, likelihood ratio of a positive test, likelihood ratio of a negative test, and diagnostic odds ratio (DOR), and rated the degree of bias of the validation method. We included ten studies evaluating eight screening tests. There was a large variation across studies regarding sample size, patient characteristics, and reference tests used for validation. Many papers failed to report on the consecutiveness of patient inclusion, time between aphasia onset and administration of the screening test, and blinding. Of the three studies that were rated as having an intermediate or low risk of bias, the DOR was highest for the Language Screening Test and ScreeLing. Several screening tools for aphasia in stroke are available, but many tests have not been verified properly. Methodologically sound validation studies of aphasia screening tests are needed to determine their usefulness in clinical practice.

Melodic Intonation Therapy in Chronic Aphasia: Evidence from a Pilot Randomized Controlled Trial.

Melodic Intonation Therapy (MIT) is a language production therapy for severely non-fluent aphasic patients using melodic intoning and rhythm to restore language. Although many studies have reported its beneficial effects on language production, randomized controlled trials (RCT) examining the efficacy of MIT are rare. In an earlier publication, we presented the results of an RCT on MIT in subacute aphasia and found that MIT was effective on trained and untrained items. Further, we observed a clear trend in improved functional language use after MIT: subacute aphasic patients receiving MIT improved considerably on language tasks measuring connected speech and daily life verbal communication. Here, we present the results of a pilot RCT on MIT in chronic aphasia and compare these to the results observed in subacute aphasia. We used a multicenter waiting-list RCT design. Patients with chronic (>1 year) post-stroke aphasia were randomly allocated to the experimental group (6 weeks MIT) or to the control group (6 weeks no intervention followed by 6 weeks MIT). Assessments were done at baseline (T1), after 6 weeks (T2), and 6 weeks later (T3). Efficacy was evaluated at T2 using univariable linear regression analyses. Outcome measures were chosen to examine several levels of therapy success: improvement on trained items, generalization to untrained items, and generalization to verbal communication. Of 17 included patients, 10 were allocated to the experimental condition and 7 to the control condition. MIT significantly improved repetition of trained items (ß = 13.32, p = 0.02). This effect did not remain stable at follow-up assessment. In contrast to earlier studies, we found only a limited and temporary effect of MIT, without generalization to untrained material or to functional communication. The results further suggest that the effect of MIT in chronic aphasia is more restricted than its effect in earlier stages post stroke. This is in line with studies showing larger effects of aphasia therapy in earlier compared to later stages post stroke. The study was designed as an RCT, but was underpowered. The results therefore have to be interpreted cautiously and future larger studies are needed. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NTR 1961.

Pantomime Production by People With Aphasia: What Are Influencing Factors?

PURPOSE: The present article aimed to inform clinical practice on whether people with aphasia (PWA) deploy pantomime techniques similarly to participants without brain damage (PWBD) and if not, what factors influence these differences. METHOD: We compared 38 PWA to 20 PWBD in their use of 6 representation techniques (handling, enact, object, shape, deictic, and other) when pantomiming objects, and determined whether PWA used the same defaults as PWBD. We assessed the influence of (non-)dominant arm use, ideomotor apraxia, semantic processing, aphasia severity, and oral naming. RESULTS: PWA used various pantomime techniques. Enact, deictic, and other were used infrequently. No differences were found for the use of shape techniques, but PWA used fewer handling and object techniques than PWBD and they did not use these for the same objects as PWBD did. No influence was found for (non-)dominant arm use. All other variables correlated with the use of handling, object, and defaults. CONCLUSION: In our study, PWA were able to use various pantomime techniques. As a group, they used these techniques differently from PWBD and relied more heavily on the use of shape techniques. This was not influenced by a hemiparesis, but seemed dependent on semantic processing. Clinical implications are discussed.

Early effect of intra-arterial treatment in ischemic stroke on aphasia recovery in MR CLEAN.

OBJECTIVE: To investigate the effect of intra-arterial treatment (IAT) on early recovery from aphasia in acute ischemic stroke. We hypothesized that the early effect of IAT on aphasia is smaller than the effect on motor deficits. METHODS: We included patients with aphasia from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), in which 500 patients with a proximal anterior circulation stroke were randomized to usual care plus IAT (<6 hours after stroke, mainly stent retrievers) or usual care alone. We estimated the effect of IAT on the shift on the NIH Stroke Scale (NIHSS) item language and the NIHSS item motor arm at 24 hours and 1 week after stroke with multivariable ordinal logistic regression as a common odds ratio, adjusted for prognostic variables (acOR). Differences between the effect of IAT on aphasia and on motor deficits were tested in a multilevel model with a multiplicative interaction term. RESULTS: Of the 288 patients with aphasia, 126 were assigned to IAT and 162 to usual care alone. The acOR for improvement of language score at 24 hours was 1.65 (95% confidence interval [CI] 1.05-2.60), and at 1 week 1.86 (95% CI 1.18-2.94). The acOR for improvement of motor deficit at 24 hours was 2.44 (95% CI 1.54-3.88), and at 1 week 2.32 (95% CI 1.43-3.77). The effect of IAT on language deficits was significantly different from the effect on motor deficits at 24 hours and 1 week (p = 0.005 and p = 0.011). CONCLUSIONS: IAT results in better early recovery from aphasia than usual care alone. The early effect of IAT on aphasia is smaller than the effect on motor deficits. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for patients with acute ischemic stroke IAT increases early recovery from aphasia and that the early effect on aphasia, as measured by the NIHSS, is smaller than the effect on motor deficits.

Optimal timing of speech and language therapy for aphasia after stroke: more evidence needed.

Aphasia due to stroke affects communication and quality of life. Most stroke survivors with aphasia receive speech and language therapy. Although an early start of treatment is advocated in clinical practice, evidence for "The earlier, the better" in aphasia rehabilitation is weak. Hence, clinicians are faced with the dilemma of when to initiate intensive treatment: as early as possible, when most of the spontaneous recovery occurs but when patients are often ill, or later, when the patients' condition is more stabilized. Here we discuss whether aphasia outcome is affected by timing of treatment in relation to stroke onset and whether there is evidence for an optimal window of time during which language therapy should be provided. Findings from various rehabilitation research fields are discussed and combined to provide principles for future research.

Insight into the neurophysiological processes of melodically intoned language with functional MRI.

BACKGROUND: Melodic Intonation Therapy (MIT) uses the melodic elements of speech to improve language production in severe nonfluent aphasia. A crucial element of MIT is the melodically intoned auditory input: the patient listens to the therapist singing a target utterance. Such input of melodically intoned language facilitates production, whereas auditory input of spoken language does not. METHODS: Using a sparse sampling fMRI sequence, we examined the differential auditory processing of spoken and melodically intoned language. Nineteen right-handed healthy volunteers performed an auditory lexical decision task in an event related design consisting of spoken and melodically intoned meaningful and meaningless items. The control conditions consisted of neutral utterances, either melodically intoned or spoken. RESULTS: Irrespective of whether the items were normally spoken or melodically intoned, meaningful items showed greater activation in the supramarginal gyrus and inferior parietal lobule, predominantly in the left hemisphere. Melodically intoned language activated both temporal lobes rather symmetrically, as well as the right frontal lobe cortices, indicating that these regions are engaged in the acoustic complexity of melodically intoned stimuli. Compared to spoken language, melodically intoned language activated sensory motor regions and articulatory language networks in the left hemisphere, but only when meaningful language was used. DISCUSSION: Our results suggest that the facilitatory effect of MIT may - in part - depend on an auditory input which combines melody and meaning. CONCLUSION: Combined melody and meaning provide a sound basis for the further investigation of melodic language processing in aphasic patients, and eventually the neurophysiological processes underlying MIT.

Should pantomime and gesticulation be assessed separately for their comprehensibility in aphasia? A case study.

BACKGROUND: Gesticulation (gestures accompanying speech) and pantomime (gestures in the absence of speech) can each be comprehensible. Little is known about the differences between these two gesture modes in people with aphasia. AIMS: To discover whether there are differences in the communicative use of gesticulation and pantomime in QH, a person with severe fluent aphasia. METHODS & PROCEDURES: QH performed two tasks: naming objects and retelling a story. He did this once in a verbal condition (enabling gesticulation) and once in a pantomime condition. For both conditions, the comprehensibility of gestures was analysed in a forced-choice task by naïve judges. Secondly, a comparison was made between QH and healthy controls for the representation techniques used. OUTCOMES & RESULTS: Pantomimes produced by QH for naming objects were significantly more comprehensible than chance, whereas his gesticulation was not. For retelling a story the opposite pattern was found. When naming objects QH gesticulated much more than did healthy controls. His pantomimes for this task were simpler than those used by the control group. For retelling a story no differences were found. CONCLUSIONS & IMPLICATIONS: Although QH did not make full use of each gesture modes' potential, both did contribute to QH's comprehensibility. Crucially, the benefits of each mode differed across tasks. This implies that both gesture modes should be taken into account separately in models of speech and gesture production and in clinical practice for different communicative settings.

Nonlinguistic cognitive impairment in poststroke aphasia: a prospective study.

BACKGROUND AND OBJECTIVES: Information on cognitive impairment in aphasic patients is limited. Our aim was to investigate the prevalence and course of nonlinguistic cognitive impairments in the first year after stroke and their association with aphasia and functional outcome. METHODS: We included 147 patients with acute aphasia. At 3 months and 1 year, we assessed cognition with a nonlinguistic cognitive examination including abstract reasoning, visual memory, visual perception and construction, and executive functioning. We assessed language with a verbal communication rating (Aphasia Severity Rating Scale), the ScreeLing (a linguistic-level screening test), and the Token Test. We evaluated functional outcome with the modified Rankin scale and registered the use of antidepressants. RESULTS: In total, 107 (88%) patients had impairments in at least one nonlinguistic cognitive domain at 3 months and 91 (80%) at 1 year. The most frequently observed impairment concerned visual memory (83% at 3 months; 78% at 1 year) and the least frequent visual perception and construction (19% at 3 months; 14% at 1 year). There was improvement on all cognitive domains including language, except for abstract reasoning. Patients with persisting aphasia had lower cognitive domain scores, worse functional outcome, and were more often depressed than patients who had recovered from aphasia. CONCLUSIONS: Standard nonlinguistic cognitive examination is recommended in aphasic stroke patients. Nonlinguistic cognitive impairments are common and associated with poor functional outcome and depression, especially in patients with persisting aphasia.

Gesturing by speakers with aphasia: how does it compare?

PURPOSE: To study the independence of gesture and verbal language production. The authors assessed whether gesture can be semantically compensatory in cases of verbal language impairment and whether speakers with aphasia and control participants use similar depiction techniques in gesture. METHOD: The informativeness of gesture was assessed in 3 forced-choice studies, in which raters assessed the topic of the speaker's message in video clips of 13 speakers with moderate aphasia and 12 speakers with severe aphasia, who were performing a communication test (the Scenario Test). Both groups were compared and contrasted with 17 control participants, who either were or were not allowed to communicate verbally. In addition, the representation techniques used in gesture were analyzed. RESULTS: Gestures produced by speakers with more severe aphasia were less informative than those by speakers with moderate aphasia, yet they were not necessarily uninformative. Speakers with more severe aphasia also tended to use fewer representation techniques (mostly relying on outlining gestures) in co-speech gesture than control participants, who were asked to use gesture instead of speech. It is important to note that limb apraxia may be a mediating factor here. CONCLUSIONS: These results suggest that in aphasia, gesture tends to degrade with verbal language. This may imply that the processes underlying verbal language and co-speech gesture production, although partly separate, are closely linked.

Recovery of aphasia after stroke: a 1-year follow-up study.

Semantics, phonology, and syntax are essential elements of aphasia diagnosis and treatment. Until now, these linguistic components have not been specifically addressed in follow-up studies of aphasia recovery after stroke. The aim of this observational prospective follow-up study was to investigate semantic, phonological, and syntactic recovery in aphasic stroke patients. In addition, we investigated the recovery of verbal communication and of aphasia severity. We assessed 147 aphasic patients at 1, 2, and 6 weeks, 3 and 6 months, and 1 year after stroke with the ScreeLing, a screening test for detecting deficits on the three main linguistic components, the aphasia severity rating scale (ASRS), a measure of verbal communication, and the Token test, a measure of aphasia severity. We investigated the differences in scores between the six time points with mixed models. Semantics and syntax improved up to 6 weeks (p < 0.001) after stroke, and phonology up to 3 months (p ≤ 0.001). ASRS improved up to 6 months (p < 0.05) and the Token test up to 3 months (p < 0.001). We conclude that in aphasia after stroke, various linguistic components have a different recovery pattern, with phonology showing the longest period of recovery that paralleled aphasia severity, as measured with the Token test. The improvement of verbal communication continues after the stabilization of the recovery of the linguistic components.

Long-term prognosis of aphasia after stroke.

BACKGROUND: The long-term functional outcome of aphasia after stroke is uncertain, even though this information is needed as early as possible for adequate patient care and support. This observational prospective study was aimed at predicting functional outcome at 1 year after stroke. METHODS: We examined linguistic components (ScreeLing) and functional verbal communication (Aphasia Severity Rating Scale, ASRS) in 147 aphasic patients. The ScreeLing was administered at 1, 2 and 6 weeks after stroke; the ASRS at 1 week and 1 year. The relationships between linguistic, demographic and stroke characteristics, and good functional outcome at 1 year (ASRS 4 or 5) were examined with logistic regression analyses. RESULTS: The baseline linguistic components (ie, semantics, phonology and syntax) were significant predictors (p<0.001) for 1-year outcome in univariable analyses. In multivariable analysis, these variables explained 46.5% of the variance, with phonology being the only significant predictor (p=0.003). Age, Barthel Index score, educational level and haemorrhagic stroke were identified as other significant predictors of outcome. A prognostic model of these five baseline predictors explained 55.7% of the variance. The internally validated area under the receiver operating characteristic curve (AUC) was 0.89, indicating good predictive performance. Adding the degree of phonological recovery between 1 and 6 weeks after stroke to this model increased the explained variance to 65% and the AUC to 0.91. CONCLUSIONS: The outcome of aphasia at 1 year after stroke can be predicted in the first week by the phonology score, the Barthel Index score, age, educational level and stroke subtype, with phonology being the strongest predictor.

Aphasia rehabilitation: more than treating the language disorder.

This supplement focuses on the neurorehabilitation of language disorders. It offers a broad survey of this field, with state-of-the-art contributions from various disciplines. In doing so, it aims to show that treating the devastating consequences of neurological language disorders requires a prolonged interdisciplinary effort.

Advanced magnetic resonance neuroimaging of language function recovery after aphasic stroke: a technical review.

Two advanced magnetic resonance neuroimaging techniques, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI), have recently made their way into clinically oriented research and hold great promise to study the brain's adaptive changes of function and structure after aphasic stroke, respectively. Such functional and structural neuroplasticity is thought to underlie the recovery of language function, occurring spontaneously and/or in the context of therapeutic intervention. With fMRI, brain activity can be visualized. Spontaneous brain activity, present in multiple brain networks, is measured with resting-state fMRI and language-related brain activity by having the subject perform a language task during scanning (task-based fMRI). With DTI the major white matter tracts, such as the dorsal and ventral language pathways and the commissural fibers, can be visualized and quantified. Both techniques are entirely noninvasive and thus offer the unique opportunity to perform multiple assessments within the same subject. To gain more insight in functional and structural neuroplasticity after aphasic stroke, advanced magnetic resonance neuroimaging studies in specific patient populations, at several stages after stroke and in the course of language recovery, are needed. Such studies will help to clarify the influence of the many factors that play a role in the recovery of language function and are thus vital to further the development of aphasia therapy. Application of these techniques in aphasic stroke patients, however, is not without challenge. The purpose of this article is to discuss the methodologic challenges of fMRI and DTI in the assessment of language recovery after aphasic stroke.

Melodic Intonation Therapy: present controversies and future opportunities.

This article describes the state of the art of Melodic Intonation Therapy (MIT), a structured aphasia therapy program using the melodic aspects of language (intonation, rhythm, and stress) to improve language production. MIT was developed in the 1970s and is still used worldwide. Nevertheless, we argue that many questions crucial for the clinical application of MIT are still unanswered. First, a review of MIT effect studies is presented showing that evidence from well-designed group studies is still lacking. It is also unclear which aspects of MIT contribute most to its therapeutic effect and which underlying neural mechanisms are involved. Two cases are presented illustrating unsolved questions concerning MIT in clinical practice, such as candidacy and the best timing of this therapy.

A 3-year evolution of linguistic disorders in aphasia after stroke.

Aphasia recovery after stroke has been the subject of several studies, but in none the deficits on the various linguistic levels were examined, even though in the diagnosis and treatment of aphasia the emphasis lays more and more on these linguistic level disorders. In this observational prospective follow-up study, we explored whether it is meaningful to investigate the recovery of semantics, phonology, and syntax separately. Fifteen patients with aphasia poststroke were assessed at 3 and 10 days, 7 weeks, 4 and 7 months, and 3 years postonset with the ScreeLing, a linguistic level test, the Aphasia Severity Rating Scale (spontaneous speech) and the Token Test. Group results showed improvement for the overall ScreeLing (P<0.01) and its subparts semantics (P<0.01) and syntax (P<0.01) up to 7 weeks, just as the Token Test (P<0.01). Phonology improved up to 4 months (P<0.05) and spontaneous speech up to 7 months (P<0.05). The recovery pattern of the three linguistic levels did not follow a parallel course, with a great deal of variability in linguistic recovery curves between and within patients. These results suggest that it is meaningful to assess the recovery of the linguistic levels separately, starting from the acute stage poststroke.