Diane L. Kendall

A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy

This investigation reports the results of a pilot study concerning the application of principles of use-dependent learning developed in the motor rehabilitation literature as Constraint Induced Therapy to language rehabilitation in a group of individuals with chronic aphasia. We compared treatment that required forced use of the language modality, Constraint Induced Language Therapy, (CILT) to treatment allowing all modes of communication. Both treatments were administrated intensively in a massed practice paradigm, using the same therapeutic stimuli and tasks. Results suggest that whereas both interventions yielded positive outcomes, CILT participants showed more consistent improvement on standard aphasia measures and clinician judgments of narrative discourse. These findings suggest that CILT intervention may be a viable approach to aphasia rehabilitation.

Conceptualizing functional cognition in stroke.

Background. Up to 65% of individuals demonstrate poststroke cognitive impairments, which may increase hospital stay and caregiver burden. Randomized stroke clinical trials have emphasized physical recovery over cognition. Neuropsychological assessments have had limited utility in randomized clinical trials. These issues accentuate the need for a measure of functional cognition (the ability to accomplish everyday activities that rely on cognitive abilities, such as locating keys, conveying information, or planning activities). Objective. The aim of the study was to present the process used to establish domains of functional cognition for development of computer adaptive measure of functional cognition for stroke. Methods. Functional cognitive domains involved in identifying relevant neuropsychological constructs from the literature were conceptualized and finalized after advisory panel feedback from experts in neurology, neuropsychology, aphasiology, clinical trials, and epidemiology. Results. The following 17 domains were proposed: receptive aphasia, expressive aphasia, agraphia, alexia, calculation, visuospatial, visuoperceptual, visuoconstruction, attention, language usage, executive functions, orientation, processing speed, memory, working memory, mood, awareness and abstract reasoning. The advisory panel recommended retaining the first 12 domains. Recommended changes included: to address only encoding and retrieval of recent information in the memory domain; to add domains for limb apraxia and poststroke depression; and to keep orientation as a separate domain or reclassify it under memory or attention. The final 10 domains included: language, reading and writing, numeric/calculation, limb praxis, visuospatial function, social use of language, emotional function, attention, executive function, and memory. Conclusion. Conceptualizing domains of functional cognition is the first step in developing a computer adaptive measure of functional cognition for stroke. Additional steps include developing, refining, and field-testing items, psychometric analysis, and computer adaptive test programming.

Phoneme-Based Rehabilitation of Anomia in Aphasia.

This study investigated the effects of phonologic treatment for anomia in aphasia. We proposed that if treatment were directed at the level of the phonologic processor, opportunities for naming via a phonological route, as opposed to a strictly whole word route, would be enhanced, thereby improving naming. The participants, ten people with anomia and aphasia due to left hemisphere stroke, received 96 h of phoneme based treatment in 12 weeks. To learn if treatment improved naming, a single-subject, repeated probe design with replication was employed. The primary outcome measure was confrontation naming. Secondary outcome measures included phonologic production, nonword repetition and discourse production. Results suggest a positive treatment effect (confrontation naming), improvements in phonologic production and nonword repetition, and generalization to discourse production. When tested 3 months after the completion of treatment the effects appeared to be maintained.

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.

Do principles of motor learning enhance retention and transfer of speech skills? A systematic review

Background: It is well documented in limb motor research that providing the optimal practice and feedback conditions can have positive outcomes for the learning of new movements. However, it remains unclear if the training conditions used for limb movements can be directly applied to the speech motor system of healthy adults and individuals with acquired motor speech disorders. Collectively these practice and feedback conditions are known as the principles of motor learning (PML), and they have recently been applied to the rehabilitation of motor speech disorders with promising results. Aims: The purpose of this systematic review is to identify which PML have been examined in the speech motor learning literature, to determine the effectiveness of these principles, and to ascertain future lines of research. Methods & Procedures: A systematic search of the literature was completed that involved the combination of a primary search term with a secondary search term. All articles were independently reviewed and scored by the first two authors. To guide the selection process strict inclusion and exclusion criteria were implemented. Additionally, authors used a 15-category evidence-rating system to judge the overall quality of each study. After the study was scored, points were totalled into an overall quality rating of high, intermediate, or low with respect to methodological rigour and interpretability. Outcomes & Results: Seven articles met inclusion criteria, including three randomised controlled trials and four single-participant designs. Five of the articles focused on motor speech disorders, including investigations of apraxia of speech (four studies) and hypokinetic dysarthria from Parkinsons disease (one study), while two studies focused on speech motor performance in healthy adults. Five of the articles were judged to be of high quality while two were judged to be of intermediate quality. Conclusions: Although limited, the current level of evidence for the application of the PML to speech motor learning in both healthy adults and individuals with motor speech disorders is promising and continued investigation is warranted.

Case study Phonological rehabilitation of acquired phonologic alexia

Background: Acquired alexia can result from impairment in either the direct (lexical) or indirect (nonlexical) reading routes. The direct route involves visual word knowledge, is supported by semantics and used to read familiar words, is especially important in irregular word reading, and cannot be used to read unfamiliar or nonwords. The nonlexical or indirect route involves parsing graphemes into component parts, application of grapheme to phoneme correspondence rules, and blending of graphemes, and is pertinent when reading unfamiliar or nonwords. Impairment of the indirect route results in either phonological or deep alexia. Several investigations have reported successful attempts in the rehabilitation of indirect route processing with minimal generalisation to untrained items. The present study reports treatment of indirect route processing using a phonological treatment approach typically used for individuals with developmental dyslexia. Aims: The aim of the present study was to investigate effects of a phonologically based rehabilitation programme on reading abilities for two adults with acquired alexia and impairment of indirect route processing. The following research questions were asked: (1) Does phonological treatment improve reading comprehension and the ability to read aloud? (2) Does treatment generalise to untreated behaviours? (3) Are treatment and generalisation effects maintained following treatment termination? Methods & Procedures: Two subjects who suffered a left hemisphere cerebral vascular accident participated in this study. A single‐subject multiple baseline design used pre and post testing and repeated treatment, generalisation, and control probes. Data were analysed using visual inspection from three judges uninvolved in this study as well as effect size (f‐statistic). Outcomes & Results: Results showed a treatment effect for real word reading aloud as well as improvement in post‐test measures of real word comprehension. The presence of a treatment effect was defined and judged to be dependent on the presence of generalisation to untreated stimuli (research question 2). Finally, treatment and generalisation effects were maintained following treatment termination. Conclusions: The phonologically based treatment programme utilised in this study was effective in treatment of the indirect route process with some effects of generalisation to behaviours such as consonant repetition, nonword repetition, real word repetition, oral praxis, and auditory syllable discrimination. These results support the view that language has a core phonological processor which comprise a neural network that links representations responsible for articulatory motor programming and naming. This study also supports the notion that phonologic treatment may be beneficial in individuals with aphasia and acquired alexia.

Influence of intensive phonomotor rehabilitation on apraxia of speech.

In this phase I rehabilitation study, we investigated the effects of an intensive phonomotor rehabilitation program on verbal production in a 73-year-old male, 11 years postonset a left-hemisphere stroke, who exhibited apraxia of speech and aphasia. In the context of a single-subject design, we studied whether treatment would improve phoneme production and generalize to repetition of multisyllabic words, words of increasing length, discourse, and measures of self-report. We predicted that a predominant motor impairment would respond to intensive phonomotor rehabilitation. While able to learn to produce individual sounds, the subject did not exhibit generalization to other aspects of motor production. Discourse production was judged perceptually slower in rate and less effortful, but also less natural. Finally, self-report indicated less apprehension toward speaking with unfamiliar people, increased telephone use, and increased ease of communication.

Errorless practice as a possible adjuvant to donepezil in Alzheimer's disease.

Six individuals with probable Alzheimers disease (AD) participated in a phase 1 study employing a repeated measures, parallel baseline design testing the hypothesis that error-free experience during word production practice combined with an acetyl cholinesterase inhibitor would improve confrontation naming ability. While acetyl cholinesterase inhibitors are safe and delay cognition decline associated with AD, improvement over baseline cognition is less evident; clinically significant cognitive deficits persist and progress. Both animal and clinical research strongly implicate acetylcholine in learning, a form of neuroplasticity. In clinical practice, however, people with AD are given cholinergic medications without concomitant systematic/targeted retraining. In this study six participants with probable AD and taking donepezil participated in targeted word production practice using an errorless learning strategy. Results showed that combining behavioral enrichment training and an acetyl cholinesterase inhibitor resulted in significant improvements in verbal confrontation naming of trained items for three of six participants. Differences in baseline dementia severity, living conditions, and medications may have influenced the training response. Detection of substantial treatment effects in 50% of subjects suggests further language treatment studies in AD in combination with an acetyl cholinesterase inhibitor are warranted and provide useful information on inclusion/exclusion criteria for use in subsequent studies.

Treatability of different components of aphasia—Insights from a case study

In this phase I clinical rehabilitation study, we investigated the effects of phonological rehabilitation for alexia and aphasia in an individual 54 years after a left-hemisphere ischemic infarction. In the context of a single-subject design, we studied whether treatment would improve phonological processing, reading, and generalization to untreated behaviors. While results showed a lack of generalization to real-word reading aloud, improvement was present in phonological processing, language function (Western Aphasia Battery Aphasia Quotient, Boston Naming Test, Reading Comprehension Battery for Aphasia), and auditory processing (Revised Token Test). Improvement in the lexical-semantic system was attributed to informal forced-use language treatment. We concluded that phonological therapies are unlikely to be successful unless a minimum initial level of phonological sequence knowledge exists; therapies that pressure subjects to use verbal communication can achieve clinically important gains in communicative ability that generalize to untreated behaviors. This study also demonstrates the importance of a careful analysis of the patients language ability before a therapeutic strategy is chosen.

Rule-based treatment for acquired phonological dyslexia

In the context of a multiple-baseline design, this study demonstrated the positive effects of behavioural treatment using grapheme to phoneme correspondence rules to treat a patient with phonological dyslexia 17 years after stroke onset. Treatment used repeated exposure to real and nonsense word stimuli embodying the regularities of two grapheme to phoneme correspondence rules (GPCR) with hierarchical cueing and knowledge of results. Results revealed a pattern of performance that increased beyond baseline variability and coincided in time with the institution of treatment. Generalization of these treatment effects occurred to words requiring knowledge of other GPCR and to an independent processing based reading measure.