Cognitive Training to Enhance Aphasia Therapy (Co-TrEAT): A Feasibility Study.

Persons with aphasia (PWA) often have deficits in cognitive domains such as working memory (WM), which are negatively correlated with recovery, and studies have targeted WM deficits in aphasia therapy. To our knowledge, however, no study has examined the efficacy of multi-modal training which includes both WM training and targeted language therapy. This pilot project examined the feasibility and preliminary efficacy of combining WM training and naming therapy to treat post-stroke PWA. Chronic PWA were randomly assigned to either the a) Phonological Components Analysis (PCA) and WM intervention (WMI) condition (i.e., a computerized adaptive dual n-back task), or b) PCA and active control condition (WMC). Participants received face-to-face PCA therapy 3 times/week for 5 weeks, and simultaneously engaged in WM training or the active control condition five times/week, independently at home. Six PWA were enrolled, 3 in each condition. Feasibility metrics were excellent for protocol compliance, retention rate and lack of adverse events. Recruitment was less successful, with insufficient participants for group analyses. Participants in the WMI (but not the WMC) condition demonstrated a clinically significant (i.e., > 5 points) improvement on the Western Aphasia Battery- Aphasia Quotient (WAB-R AQ) and Boston Naming Test after therapy. Given the small sample size, the performance of two individuals, matched on age, education, naming accuracy pre-treatment, WAB-R AQ and WM abilities was compared. Participant WMI-3 demonstrated a notable increase in WM training performance over the course of therapy; WMC-2 was the matched control. After therapy, WMI-3's naming accuracy for the treated words improved from 30 to 90% (compared to 30-50% for WMC-2) with a 7-point WAB-R AQ increase (compared to 3 for WMC-2). Improvements were also found for WMI-3 but not for WMC-2 on ratings of communicative effectiveness, confidence and some conversation parameters in discourse. This feasibility study demonstrated excellent results for most aspects of Co-TrEAT. Recruitment rate, hampered by limited resources, must be addressed in future trials; remotely delivered aphasia therapy may be a possible solution. Although no firm conclusions can be drawn, the case studies suggest that WM training has the potential to improve language and communication outcomes when combined with aphasia therapy.

Implementation and Effects of an Information Technology-Based Intervention to Support Speech and Language Therapy Among Stroke Patients With Aphasia: Protocol for a Virtual Randomized Controlled Trial.

BACKGROUND: Mobile app-based therapies are increasingly being employed by speech-language pathologists in the rehabilitation of people with aphasia as adjuncts or substitutes for traditional in-person therapy approaches. These apps can increase the intensity of treatment and have resulted in meaningful outcomes across several domains. OBJECTIVE: VoiceAdapt is a mobile therapy app designed with user and stakeholder feedback within a user-centered design framework. VoiceAdapt uses two evidence-based lexical retrieval treatments to help people with aphasia in improving their naming abilities through interactions with the app. The purpose of the randomized controlled trial (RCT) proposed here is to examine the feasibility and clinical efficacy of training with VoiceAdapt on the language and communication outcomes of people with aphasia. METHODS: A multicenter RCT is being conducted at two locations within Canada. A total of 80 people with aphasia will be recruited to participate in a two-arm, waitlist-controlled, crossover group RCT. After baseline assessment, participants will be randomized into an intervention group or a waitlist control group. The intervention group participants will engage in 5 weeks of training with the app, followed by posttreatment and follow-up assessments after an additional 5 weeks. Those in the waitlist control group will have no training for 5 weeks; this is followed by pretreatment assessment, training for 5 weeks, and posttreatment assessment. All trial procedures are being conducted remotely given the COVID-19 pandemic. RESULTS: Recruitment of participants started in September 2020, and the study is expected to be completed by March 2022. Publication of results is expected within 6 months of study completion. CONCLUSIONS: The results of the RCT will provide information on evidence-based practice using technology-based solutions to treat aphasia. If positive results are obtained from this RCT, the VoiceAdapt app can be recommended as an efficacious means of improving lexical retrieval and communicative functioning in people with aphasia in an easily accessible and a cost-effective manner. Moreover, the implementation of this RCT through remote assessment and delivery can provide information to therapists on telerehabilitation practices and monitoring of app-based home therapy programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04108364; https://clinicaltrials.gov/ct2/show/NCT04108364. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30621.

The effects of intensity on a phonological treatment for anomia in post-stroke aphasia.

INTRODUCTION: The evidence regarding optimal treatment intensity is mixed, and differing definitions have further confounded existing findings. The primary objective of this study was to compare the efficacy of Phonological Components Analysis (PCA) treatment for anomia delivered at intense and non-intense schedules, using a well-controlled design. The number of teaching episodes and active ingredients of therapy are important considerations when defining intensity. We hypothesized that an active ingredient of PCA is the self-generation of phonological components during therapy sessions. Our secondary aim was to examine whether component generation predicted treatment outcome. METHODS: Sixteen adults (M = 52.63 years old, SD = 11.40) with chronic post-stroke aphasia (M = 4.52 years post-onset, SD = 5.55) were randomly assigned to intensive (IT) or standard (ST) PCA treatment conditions. Cumulative treatment intensity in both conditions was equivalent: ST participants received PCA 1 hour/day, 3 days/week for 10 weeks, whereas IT participants received PCA 3 hours/day, 4 days/week for 2.5 weeks. The primary outcome was naming accuracy on a set of treated and (matched) untreated words, measured pre- and post-treatment, and at four- and eight-week follow-ups. RESULTS: IT and ST conditions were similarly efficacious. However, secondary analyses suggest an advantage for the IT condition in naming of the treated words immediately post-treatment, but not at follow-ups. The self-generation of phonological components emerged as a significant positive predictor of naming accuracy for both the treated and untreated words. However, this relationship did not reach significance once baseline anomia severity was accounted for. CONCLUSIONS: Although replication in a larger sample is warranted, results suggest that PCA treatment is similarly efficacious when delivered at different intensities. Other factors related to the quality of treatment (i.e., active ingredients such as cue-generation) may play an important role in determining treatment efficacy and must also be considered when comparing treatment intensities.

Mechanisms underlying anomia treatment outcomes.

Treatments for anomia have demonstrated short- and long-term efficacy. However, individual outcomes can be variable, and evidence for treatment generalization is limited. We investigated whether treatment-related measures of access to- and learning of language, namely, a) responsiveness to cues, and b) during-treatment improvements in naming, are good predictors of treatment outcomes. In addition, we investigated mechanisms underlying treatment generalization. Ten adults with chronic, post-stroke aphasia received a phonological treatment for anomia three times a week for five weeks. Naming accuracy of treated and untreated words was assessed pre- and post-treatment and at four- and eight-week follow-ups. Generalization to an untrained naming task, which involved analyses of naming accuracy and speech errors, was also assessed; speech errors were analyzed according to the Interactive Activation (IA) model of word retrieval. Group analyses indicate significant improvements in naming treated compared to untreated words, at all timepoints after therapy. Additional analyses showed significant long-term improvements in naming untreated words. Initial responsiveness to cueing and early improvement emerged as significant predictors of overall pre- to post-treatment improvements in naming treated words; naming improvements made early-on in treatment were also predictive of improvements in naming of the untreated words at follow-up. Furthermore, our study is the first to demonstrate that generalization after a phonological treatment for anomia may be driven by a strengthening of lexical-phonological connections. This study provides novel insights regarding mechanisms driving anomia treatment outcomes. Understanding such mechanisms is critical to improving existing assessment practices, optimizing treatment selection and building treatment protocols that are more likely to generalize.

Therapy-Induced Neuroplasticity in Chronic Aphasia After Phonological Component Analysis: A Matter of Intensity.

Despite the growing evidence regarding the importance of intensity and dose in aphasia therapy, few well-controlled studies contrasting the effects of intensive and non-intensive treatment have been conducted to date. Phonological components analysis (PCA) treatment for anomia has been associated with improvements in some patients with chronic aphasia; however, the effect of treatment intensity has not yet been studied with PCA. Thus, the aim of the present study was to identify the effect of intensity on neural processing associated with word retrieval abilities after PCA treatment. We used functional magnetic resonance imaging to examine therapy-induced changes in activation during an overt naming task in two patients who suffered from a stroke in the left middle cerebral artery territory. P1 received intensive PCA treatment whereas P2 received the standard, non-intensive, PCA treatment. Behavioral results indicate that both standard and intensive conditions yielded improved naming performance with treated nouns, but the changes were only significant for the patient who received the intensive treatment. The improvements were found to be long lasting as both patients maintained improved naming at 2-months follow-ups. The associated neuroimaging data indicate that the two treatment conditions were associated with different neural activation changes. The patient who received the standard PCA showed significant increase in activation with treatment in the right anterior cingulate, as well as extensive areas in bilateral posterior and lateral cortices. By contrast, the patient who received intensive PCA showed more decreases in activation following the treatment. Unexpectedly, this patient showed subcortical increase in activation, specifically in the right caudate nucleus. We speculate that the recruitment of the caudate nucleus and the anterior cingulate in these patients reflects the need to suppress errors to improve naming. Thus, both short-term intensive and standard, non-intensive, PCA treatment can improve word retrieval in chronic aphasia, but neuroimaging data suggest that improved naming is associated with different neural activation patterns in the two treatment conditions.

A Usability Study of Internet-Based Therapy for Naming Deficits in Aphasia.

Purpose: This study aimed to evaluate the usability of delivering the Phonological Components Analysis treatment for anomia (Leonard, Rochon, & Laird, 2008) remotely via the Internet to individuals with chronic poststroke aphasia. A secondary aim was to probe the experiences and satisfaction of clinicians in administering treatment at a distance. Method: Six individuals with mild-moderate aphasia and 2 trained clinicians participated in this usability study. Participants and clinicians underwent approximately 6 hr of treatment under observation by an independent observer. The usability characteristics of effectiveness, efficiency, and satisfaction were assessed. Results: Individuals with aphasia used the Internet-based Phonological Components Analysis therapy successfully, demonstrating independence and very few errors in completing online tasks. Overall, participant satisfaction was high, despite occasional difficulties with technical aspects of the system. Clinicians found the application easy to use but raised concerns about the participant-clinician interaction, perceiving rapport-building and communicating to be more difficult online than face-to-face. Conclusions: It is important to consider usability and the clinician's perspective in developing telepractice applications in speech-language pathology. Future directions include assessing the efficacy of remote treatment and collecting a larger sample of clinician data.

Neural changes after phonological treatment for anomia: An fMRI study.

Functional magnetic resonance imaging (fMRI) was used to investigate the neural processing characteristics associated with word retrieval abilities after a phonologically-based treatment for anomia in two stroke patients with aphasia. Neural activity associated with a phonological and a semantic task was compared before and after treatment with fMRI. In addition to the two patients who received treatment, two patients with aphasia who did not receive treatment and 10 healthy controls were also scanned twice. In the two patients who received treatment, both of whose naming improved after treatment, results showed that activation patterns changed after treatment on the semantic task in areas that would have been expected (e.g., left hemisphere frontal and temporal areas). For one control patient, there were no significant changes in brain activation at the second scan; a second control patient showed changes in brain activation at the second scan, on the semantic task, however, these changes were not accompanied with improved performance in naming. In addition, there appeared to be bilateral, or even more right than left hemisphere brain areas activated in this patient than in the treated patients. The healthy control group showed no changes in activation at the second scan. These findings are discussed with reference to the literature on the neural underpinnings of recovery after treatment for anomia in aphasia.

Mapping therapy for sentence production impairments in nonfluent aphasia.

This study investigated a new treatment in which sentence production abilities were trained in a small group of individuals and nonfluent aphasia. It was based upon a mapping therapy approach which holds that sentence production and comprehension impairments are due to difficulties in mapping between the meaning form (thematic roles) and the syntactic form of sentences. We trained production of both canonical and noncanonical reversible sentences. Three patients received treatment and two served as control participants. Patients who received treatment demonstrated acquisition of all trained sentence structures. They also demonstrated across-task generalisation of treated and some untreated sentence structures on two tasks of constrained sentence production, and showed some improvements on a narrative task. One control participant improved on some of these measures and the other did not. There was no noted improvement in sentence comprehension abilities following treatment. Results are discussed with reference to the heterogeneity of underlying impairments in sentence production impairments in nonfluent patients, and the possible mechanisms by which improvement in sentence production might have been achieved in treatment.