Edna M. Babbitt

Epidural cortical stimulation and aphasia therapy

Background: There are several methods of delivering cortical brain stimulation to modulate cortical excitability, and interest in their application as an adjuvant strategy in aphasia rehabilitation after stroke is growing. Epidural cortical stimulation, although more invasive than other methods, permits high-frequency stimulation of high spatial specificity to targeted neuronal populations. Aims: First we review evidence supporting the use of epidural cortical stimulation for upper limb recovery after focal cortical injury in both animal models and human stroke survivors. These data provide the empirical and theoretical platform underlying the use of epidural cortical stimulation in aphasia. Second, we summarise evidence for the application of epidural cortical stimulation in aphasia. We describe the procedures and primary outcomes of a safety and feasibility study (Cherney, Erickson, & Small, 2010), and provide previously unpublished data regarding secondary behavioural outcomes from that study. Main Contribution: In a controlled study comparing epidural cortical stimulation plus language treatment (CS/LT) to language treatment alone (LT), eight stroke survivors with nonfluent aphasia received intensive language therapy for 6 weeks. Four of these participants also underwent surgical implantation of an epidural stimulation device, which was activated only during therapy sessions. Behavioural data were collected before treatment, immediately after treatment, and at 6 and 12 weeks following the end of treatment. The effect size for the primary outcome measure, the Western Aphasia Battery Aphasia Quotient, was benchmarked as moderate from baseline to immediately post-treatment, and large from baseline to the 12-week follow-up. Similarly, effect sizes obtained at the 12-week follow-up for the Boston Naming Test, the Communicative Effectiveness Index, and for correct information units on a picture description task were greater than those obtained immediately post treatment. When effect sizes were compared for individual participant pairs on discourse measures of content and rate, effects were typically larger for the investigational participants receiving CS/LT than for the control participants receiving LT alone. These analyses support previous findings regarding therapeutic efficacy of CS/LT compared to LT, i.e., epidural stimulation of ipsilesional premotor cortex may augment behavioural speech-language therapy, with the largest effects after completion of therapy. Conclusions: Continued investigation of epidural cortical stimulation in combination with language training in post-stroke aphasia should proceed cautiously. Carefully planned studies that customize procedures to individual profiles are warranted. Information from research on non-invasive methods of CS/LT may also inform future studies of epidural cortical stimulation.

Communication Confidence in Persons with Aphasia

Abstract Communication confidence is a construct that has not been explored in the aphasia literature. Recently, national and international organizations have endorsed broader assessment methods that address quality of life and include participation, activity, and impairment domains as well as psychosocial areas. Individuals with aphasia encounter difficulties in all these areas on a daily basis in living with a communication disorder. Improvements are often reflected in narratives that are not typically included in standard assessments. This article illustrates how a new instrument measuring communication confidence might fit into a broad assessment framework and discusses the interaction of communication confidence, autonomy, and self-determination for individuals living with aphasia.

Psychometric properties of the communication confidence rating scale for aphasia (CCRSA): Phase 1

Abstract Confidence is a construct that has not been explored previously in aphasia research. We developed the Communication Confidence Rating Scale for Aphasia (CCRSA) to assess confidence in communicating in a variety of activities and evaluated its psychometric properties using rating scale (Rasch) analysis. The CCRSA was administered to 21 individuals with aphasia before and after participation in a computer-based language therapy study. Person reliability of the 8-item CCRSA was .77. The 5-category rating scale demonstrated monotonic increases in average measures from low to high ratings. However, one item (“I follow news, sports, stories on TV/movies”) misfit the construct defined by the other items (mean square infit = 1.69, item-measure correlation = .41). Deleting this item improved reliability to .79; the 7 remaining items demonstrated excellent fit to the underlying construct, although there was a modest ceiling effect in this sample. Pre- to posttreatment changes on the 7-item CCRSA measure were statistically significant using a paired samples t test. Findings support the reliability and sensitivity of the CCRSA in assessing participants’ self-report of communication confidence. Further evaluation of communication confidence is required with larger and more diverse samples.

Structure, Processes, and Retrospective Outcomes From an Intensive Comprehensive Aphasia Program

PURPOSE This study describes the structure, processes, and outcomes of an intensive comprehensive aphasia program (ICAP). The aim was to identify treatment gains and determine if outcomes were significantly different between participants grouped according to severity and type of aphasia, and time postonset. METHOD Data from 74 first-time ICAP participants were analyzed. Pre- and posttreatment scores on the Western Aphasia Battery-Revised and other impairment and participation measures were compared using paired t tests. Analyses of variance were used to compare outcomes related to aphasia severity (severe, moderate, and mild aphasia), aphasia type (fluent, nonfluent), and chronicity (0-6 months postonset, 7-12 months postonset, and 12+ months postonset). RESULTS Participants made significant changes on all impairment and participation measures. Large effect sizes were noted for one participation and three impairment measures. Medium effect sizes were noted for one impairment and three participation measures. There was no significant difference among groups on any factor. CONCLUSION ICAPs can have a significant effect on the language impairment and participation of people with aphasia, but further research is required to determine if the effect is comparable to other types of service delivery.

Transcranial direct current stimulation and aphasia: the case of mr. C.

Abstract Purpose: To illustrate the ethical challenges that arose from investigating a novel treatment procedure, transcranial direct current stimulation (tDCS), in a research participant with aphasia. Method: We review the current evidence supporting the use of tDCS in aphasia research, highlighting methodological gaps in our knowledge of tDCS. Then, we examine the case of Mr. C, a person with chronic aphasia who participated in a research protocol investigating the impact of tDCS on aphasia treatment. We describe the procedures that he underwent and the resulting behavioral and neurophysiological outcomes. Finally, we share the steps that were taken to balance beneficence and nonmaleficence and to ensure Mr. C’s autonomy. Results: The objective data show that while Mr. C may not have benefitted from participating in the research, neither did he experience any harm. Conclusion: Researchers must consider not only the scientific integrity of their studies, but also potential ethical issues and consequences to the research participants.

Who benefits from an intensive comprehensive aphasia program

Purpose: This article summarizes current outcomes from intensive comprehensive aphasia programs (ICAPs) and examines data from one ICAP to identify those who respond and do not respond to treatment. Methods: Participants were divided into 2 groups, responders and nonresponders, based on ±5-point change score on the Western Aphasia Battery–Revised Aphasia Quotient. Independent-samples t tests and &khgr;2 tests were performed to identify differences between groups on demographic (age and gender) and aphasia-related factors (months postonset, type of aphasia, aphasia severity, naming, nonverbal cognition measure, and self-rating of communication confidence). Logistic regression determined if factors contributed to a treatment response. Results: There were significant differences between the groups on age and months postonset. Gender, type of aphasia, naming, nonverbal cognitive measure, and communication confidence were not significantly different. Logistic regression indicated that age was the only predictive factor contributing to treatment response. Conclusions: This study only identified age as a predictor of responders. Future research may need to examine a broader scope of variables that can impact recovery in aphasia.

Clinician perspectives of an intensive comprehensive aphasia program.

Abstract Background: Intensive comprehensive aphasia programs (ICAPs) have increased in number in recent years in the United States and abroad. Objective: To describe the experiences of clinicians working in an ICAP. Methods: A phenomenological approach was taken. Seven clinicians from 3 ICAPs were interviewed in person or on the phone. Their interviews were transcribed and coded for themes relating to their experiences. Results: Clinicians described 3 major themes. The first theme related to the intensity component of the ICAP that allowed clinicians to provide in-depth treatment and gave them a different perspective with regard to providing treatment and the potential impact on the person with aphasia. The second theme of rewards for the clinicians included learning and support, seeing progress, and developing relationships with their clients and family members. Third, challenges were noted, including the time involved in learning new therapy techniques, patient characteristics such as chronicity of the aphasia, and the difficulty of returning to work in typical clinical settings after having experienced an ICAP. Conclusions: Although there is a potential for bias with the small sample size, this pilot study gives insight into the clinician perspective of what makes working in an ICAP both worthwhile and challenging.

A core outcome set for aphasia treatment research: the ROMA consensus statement

Background A core outcome set (COS; an agreed, minimum set of outcomes) was needed to address the heterogeneous measurement of outcomes in aphasia treatment research and to facilitate the production of transparent, meaningful, and efficient outcome data. Objective The Research Outcome Measurement in Aphasia (ROMA) consensus statement provides evidence-based recommendations for the measurement of outcomes for adults with post-stroke aphasia within phases I–IV aphasia treatment studies. Methods This statement was informed by a four-year program of research, which comprised investigation of stakeholder-important outcomes using consensus processes, a scoping review of aphasia outcome measurement instruments, and an international consensus meeting. This paper provides an overview of this process and presents the results and recommendations arising from the international consensus meeting. Results Five essential outcome constructs were identified: Language, communication, patient-reported satisfaction with treatment and impact of treatment, emotional wellbeing, and quality of life. Consensus was reached for the following measurement instruments: Language: The Western Aphasia Battery Revised (WAB-R) (74% consensus); emotional wellbeing: General Health Questionnaire (GHQ)-12 (83% consensus); quality of life: Stroke and Aphasia Quality of Life Scale (SAQOL-39) (96% consensus). Consensus was unable to be reached for measures of communication (where multiple measures exist) or patient-reported satisfaction with treatment or impact of treatment (where no measures exist). Discussion Harmonization of the ROMA COS with other core outcome initiatives in stroke rehabilitation is discussed. Ongoing research and consensus processes are outlined. Conclusion The WAB-R, GHQ-12, and SAQOL-39 are recommended to be routinely included within phases I–IV aphasia treatment studies. This consensus statement has been endorsed by the Collaboration of Aphasia Trialists, the British Aphasiology Society, the German Society for Aphasia Research and Therapy, and the Royal College of Speech Language Therapists.

Does type of aphasia impact change on the Communication Confidence Rating Scale for Aphasia (CCRSA)

Background: Communication confidence is a psychological construct that may improve following language treatment. Ross, Winslow, Marchant, and Brumfitt (2006) conducted a small study examining outcomes from a group treatment model. They noted that scores on self-esteem measures did not change significantly, but improved confidence was remarked on by all the participants in an informal survey after the study. Corsten, Konradi, Schimpf, Hardering, and Keilmann (2014) found that self-reported measures of life-satisfaction did not change following treatment; however, self-confidence and communication were rated higher. In a survey of practicing clinicians, 99% of clinicians agreed or strongly agreed that addressing confidence along with psychological well-being was important (Northcott, Simpson, Moss, Ahmed, & Hilari, 2016). While there is consensus that it is important to measure changes in communication confidence following treatment, the Communication Confidence Rating Scale for Adults (CCRSA) is currently the only standardized measure of communication confidence for persons with aphasia (Babbitt, Heinemann, Semik, & Cherney, 2011). It is increasingly being used across research studies, but it is unknown if persons with different types of aphasia respond differently on the measure. Aims: The purpose of this studywas to explorewhether: (1) the CCRSAmeasures changes in communication confidence following different treatments and (2) persons with different types of aphasia (non-fluent and fluent) report similar changes on the CCRSA. Methods: We examined preto posttreatment performance on the Communication Confidence Rating Scale for Aphasia (CCRSA) by 215 subjects who took part in different research studies that lasted 6 weeks or a clinical intensive aphasia program that lasted 4 weeks. A total of 151 of the participants had non-fluent aphasia and 64 participants had fluent aphasia. Ages ranged from 18 to 86 years (mean = 55.3, SD = 14.3), months postonset ranged from 3 to 188 months (mean = 23.3, SD = 26.3), and the Western Aphasia Battery – Revised Aphasia Quotient (WAB-R AQ) scores ranged from 7 to 92.1/100 (mean = 56.5, SD = 20.9). A general linear model (GLM) approach was used. Results: At baseline, the non-fluent and fluent aphasia groups differed significantly on age, months post-onset, and WAB-R AQ. However, there was no significant difference in CCRSA scores for the non-fluent and fluent aphasia groups. All participants improved

Factors contributing to improvements after an intensive comprehensive aphasia program

Habitat loss is viewed as a primary cause of pollinator population declines. Managed meadows and gardens provide benefits to wildlife, including pollinating insects. Given the interest in planting flowers for pollinators, lists of recommended varieties have been produced by professional organizations and amateurs alike. These lists serve as a good starting point but are often not grounded in empirical data. Coreopsis is a popular garden plant and a frequent component of commercial pollinator seed mixes. The aim of this study is to compare the ecological role of commercially available Coreopsis plants. It is hypothesized that pollinating insects exhibit preferences based on color and other floral traits. To address this question 4 species of wildtype Coreopsis and 13 cultivars were evaluated for their attractiveness to pollinating insects. Data was collected between June and August 2014 from Coreopsis plants in the Mount Cuba Center trial garden (Hockessin, Delaware). Flower visitors were observed and recorded to morphospecies. To assess which visual floral traits were correlated with pollinator visitation, inflorescence diameter, inflorescences per plant, inflorescence color and pattern, plant height, and number of flowers per inflorescence were measured. Correlating visitation with floral traits may explain the differential attraction of pollinators to Coreopsis flowers. David Ray The Nature Conservancy, MD/DC Chapter Atlantic White-Cedar Stand History and Rehabilitation Prospects Abstract: Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. POSTER PRESENTATIONS Larry Murrell Air Infusion removes Biomat-Lining of Septic Stone-Filled Trench in less than Six Hours: New Protocol to Restore Impaired Septic System Function It is widely recognized that soil decline of residential properties in New Jersey follows a pattern of 1) waterlogging, 2) anaerobic-bacteria-generated toxins impairing plant health, 3) compaction, 4) rapid erosion, and 5) rising water tables. Use of pesticides and inorganic fertilizers accelerate the compaction and erosion in a vicious cycle. These negative impacts on soil health have a domino effect causing chronically high, usually perched water tables, contributing to water-logging and basement flooding. What is not widely recognized is that the soil surrounding the trenches of septic systems, also called drainfields or laterals, is highly susceptible to water-logging and the increasing water tables found all along the Eastern Seaboard. A high water table for septic fields promotes rapid formation of a 1-2” thick black biomat that forms in the surrounding soil. This biomat leads to compromised water flow from the stone-filled trench, or drainfield, into the septic field, and eventually to complete failure of the septic system. We have found that an effective way to attack the biomat of a septic system in a one-step procedure that destroys the biomat and allows the entrained waste water in the gravel train to surge into the soil of the septic field, literally saturating the soil of the field. Once this entrained waste water is transferred to the soil, natural aerobic bacteria digest the remains of the biomat and any toxins present in the field. This new protocol is effective because it saturates void spaces in the trench, and then saturates the entire septic field with aerated water. The restoration process is cost effective and takes only 6 8 hours to complete for each trench of a septic system. With our protocol, the entire biomat is destroyed by uniform air-infusion to the entire trench, and subsequently to the entire field. Samantha Nestory and Judy HoughGoldstein University of Delaware Entomology and Wildlife Ecology Mechanical control methods for Japanese stiltgrass (Microstegium vimineum) Abstract: Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. POSTER PRESENTATIONS Monica Gagliardi Temple University School of Environmental Design ML Architect Student Oxford Wetland Sanctuary: What Nature Intended Abstract: In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. Wetland mitigation banking represents an important economic component of the environmental sector, showcasing synergies between effective environmental protection and economic expansion while elevating the value of wetlands in society. The plan uses strategic micro grading and native re-vegetation to create a complex system that absorbs rainwater and slowly releases it to the aquifer; absorbs chem