Helen Kelly

New word learning in people with aphasia

Background: The theory of speech and language therapy intervention for people with aphasia is still under‐articulated, and some people with aphasia respond better to therapy than others. The reasons for individual variation in response to therapy have not yet been fully established but may partially reflect a person with aphasias ability to utilise a range of cerebral mechanisms, such as re‐accessing damaged neural pathways and establishing new ones. Most current therapies aim to help the person with aphasia access their previously available language abilities. New learning may offer an alternative therapy approach. However, there is little evidence to date on the effect of aphasia on a persons capability to learn new linguistic information. Aim: To explore the new vocabulary learning potential of people with aphasia. Methods & Procedures: Twelve participants, under the age of 65 years and with a range of aphasia severity and personal backgrounds, were taught 20 novel words over four consecutive days. Their learning of this new vocabulary was measured via a range of single‐word processing tasks based on the cognitive neuropsychological model. Ten participants repeated the tasks a few days later to establish whether the new vocabulary had been retained in long‐term memory. Outcomes & Results: All of the participants demonstrated some ability to learn the new vocabulary (both novel word forms and novel word meanings), with scores ranging from 15% to 99% on the various assessments. At the follow‐up session, the ten participants retained between 49% and 83% of their previous scores. Conclusions: This study has important implications for aphasia rehabilitation as it has shown that people with aphasia have the potential to learn new linguistic material, even in the presence of severe language impairments. This capacity could be exploited in therapy. Previously known words could be taught as new. Pre‐therapy assessment of the person with aphasias learning capacity and style would promote individually‐tailored learning experiences and so, potentially, more effective therapy and better clinical outcomes.

Assessment and Treatment of Short-Term and Working Memory Impairments in Stroke Aphasia: A Practical Tutorial.

BACKGROUND Aphasia following stroke refers to impairments that affect the comprehension and expression of spoken and/or written language, and co-occurring cognitive deficits are common. In this paper we focus on short-term and working memory impairments that impact on the ability to retain and manipulate auditory-verbal information. Evidence from diverse paradigms (large group studies, case studies) report close links between short-term/working memory and language functioning in aphasia. This evidence leads to the hypothesis that treating such memory impairments would improve language functioning. This link has only recently been acknowledged in aphasia treatment but has not been embraced widely by clinicians. AIMS To examine the association between language, and short-term and working memory impairments in aphasia. To describe practical ways of assessing short-term and working memory functioning that could be used in clinical practice. To discuss and critically appraise treatments of short-term and working memory reported in the literature. METHODS & PROCEDURES Taking a translational research approach, this paper provides clinicians with current evidence from the literature and practical information on how to assess and treat short-term and working memory impairments in people with aphasia. Published treatments of short-term and/or working memory in post-stroke aphasia are discussed through a narrative review. MAIN CONTRIBUTIONS This paper provides the following. A theoretical rationale for adopting short-term and working memory treatments in aphasia. It highlights issues in differentially diagnosing between short-term, working memory disorders and other concomitant impairments, e.g. apraxia of speech. It describes short-term and working memory assessments with practical considerations for use with people with aphasia. It also offers a description of published treatments in terms of participants, treatments and outcomes. Finally, it critically appraises the current evidence base relating to the treatment of short-term and working memory treatments. CONCLUSIONS The links between short-term/working memory functioning and language in aphasia are generally acknowledged. These strongly indicate the need to incorporate assessment of short-term/working memory functioning for people with aphasia. While the supportive evidence for treatment is growing and appears to highlight the benefits of including short-term/working memory in aphasia treatment, the quality of the evidence in its current state is poor. However, because of the clinical needs of people with aphasia and the prevalence of short-term/working memory impairments, incorporating related treatments through practice-based evidence is advocated.

Narrowing the “digital divide”—facilitating access to computer technology to enhance the lives of those with aphasia: a feasibility study

Background: Despite advances in technology and the universal accessibility of the Internet, the aptly named “digital divide” still prevents equal access to, and use of, computer technology by people with aphasia. The use of technology has clear potential for improved quality of life in terms of increased methods for communicating as well as the facilitation of self-management; however, substantial barriers still pervade. Aims: The aims of this study were to evaluate a bespoke computer training course appropriate for people with aphasia and examine the personal experiences of a small sample of individuals with aphasia following their participation on the course. Methods & Procedures: This feasibility study with mixed-methods evaluation recruited participants with a range of aphasia severity and different experiences in using computers. Participants (n = 17) discussed their personal experiences of attending the computer course, gathered through topic-guided small focus groups, immediately postcourse and follow-up Refresher class. A Framework Method approach was considered an appropriate methodological design and data were analysed using thematic analysis. Participants also self-rated their skills in using computers before and following this bespoke computer course (n = 16) and at follow-up (n = 10), which was statistically analysed. Outcomes & Results: Statistically significant differences were found in the improved self-rated ability of a range of computer skills following course attendance. However, participants who attended a Refresher class (5, 9, or 12 months following course completion) reported that without support a number of these skills had notably declined. Three main themes emerged from the focus group data: (i) Facilitation of Social Engagement—technology offered new opportunities to communicate and more independently self-manage day-to-day tasks; (ii) Course Framework—participants reflected on their preferred model of delivery of the course; and finally (iii) Overcoming Barriers to Technology—the advantages of bespoke computer training, and requirements for ongoing support were highlighted as essential components of a training course appropriate for people with aphasia. Conclusions: The personal experiences of this group of people with aphasia highlight the advantages of accessing technology as a way of facilitating increased communication and an enhanced ability to manage their day-to-day lives. Yet, despite these benefits and the necessity for many people with aphasia to learn or relearn computer skills, finding courses that can accommodate individual needs is problematic. This research highlights the need for bespoke computer training and follow-on support, and highlights the necessary components of such training as identified by this group of people with aphasia.

Speech and Language Therapy for Aphasia After Stroke

Aphasia significantly affects the individual, families, and communities. Timely, effective intervention is vital. Speech and language therapy (SLT) is a complex rehabilitation intervention targeting improvement in language and communication abilities (verbal comprehension, spoken language, reading, writing), activity, and participation. Therapy may vary in intervention regimen, theoretical approach, or delivery model. Our comprehensive updated review1 synthesized evidence of the effectiveness of SLT for aphasia after stroke found in randomized control trials compared with (1) no therapy and (2) other SLT interventions. We searched a range of databases, including the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, Cochrane Library Databases, MEDLINE, EMBASE, CINAHL, AMED (Allied and Complementary Medicine Database), LLBA (Linguistics and Language Behaviour Abstracts), and SpeechBITE (Speech Pathology Database for Best Interventions and Treatment Efficacy) (all from inception to September 2015). We also searched …

Attention control comparisons with SLT for people with aphasia following stroke: methodological concerns raised following a systematic review:

Objective: Attention control comparisons in trials of stroke rehabilitation require care to minimize the risk of comparison choice bias. We compared the similarities and differences in SLT and social support control interventions for people with aphasia. Data sources: Trial data from the 2016 Cochrane systematic review of SLT for aphasia after stroke Methods: Direct and indirect comparisons between SLT, social support and no therapy controls. We double-data extracted intervention details using the template for intervention description and replication. Standardized mean differences and risk ratios (95% confidence intervals (CIs)) were calculated. Results: Seven trials compared SLT with social support (n  =  447). Interventions were matched in format, frequency, intensity, duration and dose. Procedures and materials were often shared across interventions. Social support providers received specialist training and support. Targeted language rehabilitation was only described in therapy interventions. Higher drop-out (P  =  0.005, odds ratio (OR) 0.51, 95% CI 0.32–0.81) and non-adherence to social support interventions (P  <  0.00001, OR 0.18, 95% CI 0.09–0.37) indicated an imbalance in completion rates increasing the risk of control comparison bias. Conclusion: Distinctions between social support and therapy interventions were eroded. Theoretically based language rehabilitation was the remaining difference in therapy interventions. Social support is an important adjunct to formal language rehabilitation. Therapists should continue to enable those close to the person with aphasia to provide tailored communication support, functional language stimulation and opportunities to apply rehabilitation gains. Systematic group differences in completion rates is a design-related risk of bias in outcomes observed.

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.

Speech and language therapists’ perspectives of ICT use in aphasia rehabilitation

Background: The use of technology in aphasia rehabilitation is promoted as an efficient route for the delivery of intensive speech and language therapy (Code & Petheram, 2011). Information Communications Technology (ICT) hardware has become more affordable and accessible, with a parallel proliferation of available therapeutic software in the forms of computer programmes and applications for smartphones and tablets. Research has begun to explore the views of people with aphasia (PwA) in relation to specific ICT-delivered therapeutic programmes in aphasia rehabilitation (Palmer, Enderby, & Paterson, 2013), but there is limited consideration of the prescriber views (i.e., speech and language therapists). Therapists consider a range of factors when making decisions about technology use in stroke rehabilitation (Chen & Bode, 2011). These factors come from three different facets: patient, provider (i.e., health professional), and the larger context (i.e., health service). Theoretical frameworks of technology acceptance such as the Unified Theory of Acceptance and Use of Technology may be useful when investigating factors that influence therapists’ acceptance and employment of new technologies in rehabilitation (Liu et al., 2015). Aims: To explore speech and language therapists’ views of ICT in aphasia rehabilitation. To identify factors that influence clinical decision-making when integrating ICT into aphasia rehabilitation. Methods and procedures: Speech and language therapists (n = 15) were recruited from a range of clinical settings in the Republic of Ireland and invited to participate in one of four focus groups. Each group discussion was facilitated by an SLT researcher, data were audio recorded and transcribed. Analysis was completed independently by two researchers following Braun and Clarke’s six phases of thematic analysis (Braun & Clarke, 2006). After coding each transcript, the two researchers discussed the codes and emerging themes. Where discrepancies occurred, the codes and unit meanings were discussed and agreement was reached by consensus. The candidate themes were reviewed and refined in conjunction with a third researcher. Finally, the themes were then defined and named. Outcomes and results: Five key themes emerged from the focus group discussions; Support, Resources and Access, Function and Use, Attitudes and Skills, and the Impact of ICT. The SLTs discussed a wide variety of factors – at patient, provider, and wider context level – that influence their decision to introduce ICT in aphasia rehabilitation. Some factors identified by the SLTs are internal to the therapeutic relationship between the

Self-administered aphasia rehabilitation targeting auditory comprehension; exploring feasibility and acceptance of ICT-delivered rehabilitation

Background: Speech and language therapy can provide beneficial outcomes in aphasia rehabilitation and intensity is a key component of a successful programme (Brady et al. 2016). Information and Communication Technologies (ICT) offer an option for the delivery of intensive aphasia rehabilitation. A systematic review of seven randomised controlled trials investigating computer therapy in aphasia rehabilitation (two of which targeted auditory comprehension) suggests that computer therapy is effective when compared to no therapy and may be as effective as clinician-delivered therapy for specific conditions (Zheng et al. 2016). When considering ICT-delivered rehabilitation, it is also important to explore the views of people with aphasia (PwA), to understand motivation and engagement with self-administered rehabilitation. There is no consensus measure of user experience in ICT-delivered aphasia rehabilitation. Studies have employed semi-structured interviews, usage data and observations to explore feasibility, experience and satisfaction with this mode of therapy (Marshall et al. 2013; Palmer et al. 2013). The NASA Task Load Index (NASA TLX) is a subjective assessment which measures perceived workload of a specific task. It consists of six subscales: Mental, Physical, and Temporal Demands, Performance, Effort, and Frustration (Hart, 2006). It was originally designed for use in aviation but has also been used in stroke rehabilitation research. A co-design process with PwA was employed to improve accessibility of this assessment. Aims: To investigate workload, feasibility, and acceptance of ICT-delivered aphasia rehabilitation for auditory comprehension deficits at sentence level. Methods & Procedures: A case series experimental two-phase crossover treatment design was employed which compared a self-administered aphasia software rehabilitation programme, targeting auditory language comprehension, with a self-administered sham programme not targeting language. This multiple baseline design included random allocation to phase. Both quantitative and qualitative data were gathered. Repeated cognitive and language assessments, as well as quality of life and control measures were completed at baseline and after each phase. A feedback questionnaire incorporating an aphasia accessible version of the NASA TLX, observations, and semistructured interviews were carried out midway through each phase. This data were

The methodological quality of short-term/working memory treatments in post-stroke aphasia: a systematic review

Background: Individuals with aphasia after stroke often present with concomitant shortterm memory and working memory (STM/WM) impairments (Murray, Salis, Martin, & Dralle, 2018). These impairments can negatively influence language processing (e.g., Martin, Minkina, Kohen, & Kalinyak-Fliszar, 2018; Salis, Kelly, & Code, 2015; Zakariás, Salis, & Wartenburger, 2018). Research investigating the relationship between STM/WM and language processing has led to the promising hypothesis that treatments of STM/WM could lead to improvements in language functioning, a phenomenon known as generalization. However, despite the growing number of STM/WM treatments in aphasia, little is known about their methodological rigor and quality, and whether treatment-related improvements of STM/WM generalize beyond STM/WM treatment tasks and to aspects of language (e.g., spoken sentence comprehension). Aims: (1) To identify and describe STM/WM treatments in stroke aphasia through a systematic review of relevant literature; (2) to appraise the methodological quality (i.e., internal and external validity) of these treatments; (3) to investigate whether STM/WM, language (e.g., spoken sentence comprehension, functional communication), and other everyday functions can benefit from STM/WM treatments in stroke aphasia. Methods & procedures: A systematic search of 13 databases was conducted in 2014 (February) and then updated in 2016 (December). Reference lists of included studies, conference abstracts, and relevant reviews were also screened for potentially eligible studies. Inclusion criteria were studies that had been published in English and included: (1) adult participants presenting with non-progressive, acquired aphasia as a result of stroke; (2) STM/WM tasks in their treatments; (3) STM/WM outcome data. We used the Risk of Bias in N-of-1 Trials (RoBiNT; Tate et al., 2015) quantitative scale to rate the internal and external validity of the included studies. Outcomes & results: The selection and inclusion process is summarized in Figure 1. The systematic search and inclusion/exclusion procedure yielded 17 included studies (mainly single case and case-series designs) with 37 participants. Table 1 summarizes the included studies (not included in the reference list), methodological quality scores, treatment procedures, and main outcomes. Methodological quality scores indicated poor internal and external validity across studies. The majority of studies reported

Comparison choice bias and trials of speech and language therapy for aphasia – some methodological considerations

Background: Control comparisons in trials of speech and language therapy interventions for people with aphasia after stroke require careful consideration and should seek to minimize the chance of incorrectly perceiving interventions as more (or less) effective than they actually are (one consequence of comparison choice bias). Social support is an important adjunct to formal language rehabilitation approaches while therapists typically enable those close to the person with aphasia to provide tailored communication support, functional language stimulation and opportunities to apply rehabilitation gains. We considered the use of social support attention control comparisons in trials of speech and language therapy for aphasia after stroke. Aim: We compared the similarities and differences in randomized controlled trials of speech and language therapy where people with aphasia after stroke were randomly allocated to receive therapy or a social support control intervention. Methods: Two reviewers independently extracted the data from randomized controlled trials included in the 2016 Cochrane systematic review of speech and language therapy for aphasia after stroke (Brady, Kelly, Godwin, Enderby, & Campbell, 2016). We extracted details of the intervention using the Template for Intervention Description and Replication checklist (TIDieR; Hoffmann et al., 2014). We also gathered information on those that failed to complete the trial (dropouts for any reason) and those that declined to continue (non-adherence) by group allocation which has been used within reviews as an indicator of intervention acceptability (Sekhon, Cartwright, & Francis, 2017). We calculated standardized mean differences and risk ratios (95% confidence intervals) and made direct and indirect comparisons between speech and language therapy interventions and social support and no therapy controls. Results: Nine trials compared speech and language therapy with a social support intervention (n = 447). Statistical data supporting the meta-analyses of language outcomes were available for six trials while all nine trials contributed to drop-out and intervention analyses. The format, location, frequency, weekly intensity, duration, and dose of comparison interventions were generally matched. Trialists shared procedures and materials amongst those delivering the comparison interventions. Training, ongoing