Leora R. Cherney

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Purpose— The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. Conclusions— As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.)

Aphasia, Alexia, and Oral Reading

Abstract Alexia is an acquired disturbance in reading. Alexias that occur after left hemisphere damage typically result from linguistic deficits and may occur as isolated symptoms or as part of an aphasia syndrome. This article presents an overview of the classification of the alexias, including both the traditional neuroanatomical perspective and the more recent psycholinguistic approach. Then, assessment procedures are reviewed, followed by a summary of treatment approaches for alexia. Finally, two case studies illustrate how oral reading of connected language (sentences and paragraphs rather than single words) has been used as a technique for treating alexia in patients with aphasia.Alexia is an acquired disturbance in reading. Alexias that occur after left hemisphere damage typically result from linguistic deficits and may occur as isolated symptoms or as part of an aphasia syndrome. This article presents an overview of the classification of the alexias, including both the traditional neuroanatomical perspective and the more recent psycholinguistic approach. Then, assessment procedures are reviewed, followed by a summary of treatment approaches for alexia. Finally, two case studies illustrate how oral reading of connected language (sentences and paragraphs rather than single words) has been used as a technique for treating alexia in patients with aphasia.

Oral Reading for Language in Aphasia (ORLA): Evaluating the Efficacy of Computer-Delivered Therapy in Chronic Nonfluent Aphasia

Abstract Purpose: This study examined the efficacy of a treatment, Oral Reading for Language in Aphasia (ORLA), delivered by computer to individuals with chronic nonfluent aphasia and compared its efficacy with the same treatment delivered by a speech-language pathologist (SLP). Method: With ORLA, the person with aphasia systematically and repeatedly reads aloud sentences, first in unison and then independently. Following a no-treatment period, 25 individuals with chronic nonfluent aphasia were randomly assigned to receive 24 sessions of ORLA, 1–3 times per week, either by computer or by the SLP. Results: For participants receiving computer ORLA, change made on the Western Aphasia Battery Aphasia Quotient (WAB-AQ) during the treatment phase was larger than the change made during the no-treatment phase. Positive effect sizes for change during treatment compared with change during the no-treatment phase were obtained and were benchmarked as medium or large for the WAB-AQ and discourse measures. There was no significant difference between outcomes for computer ORLA compared with SLP-ORLA. Conclusion: Low-intensity ORLA, delivered by computer to individuals with chronic nonfluent aphasia, is efficacious and may be equivalent to ORLA delivered by an SLP.

Intensity of Aphasia Therapy: Evidence and Efficacy

Determining the optimal amount and intensity of treatment is essential to the design and implementation of any treatment program for aphasia. A growing body of evidence, both behavioral and biological, suggests that intensive therapy positively impacts outcomes. We update a systematic review of treatment studies that directly compares conditions of higher and lower intensity treatment for aphasia. We identify five studies published since 2006, review them for methodologic quality, and synthesize their findings with previous ones. For both acute and chronic aphasia, results at the language impairment and communication activity/participation levels tend to be more equivocal than previously demonstrated, with no clear differences between intensive and nonintensive treatment emerging across studies. Future research directions are discussed including research design, definitions of treatment intensity, and behavioral and biological measurement of short- and long-term changes following implementation of an intensive treatment.

Aphasia treatment: Intensity, dose parameters, and script training

Abstract Studies of aphasia treatment have shown that intensive speech-language therapy is associated with significant improvements. However, there is no standard definition of intensity and the simplistic notion that “more is better” is not necessarily supported by the research. First, current evidence regarding intensity and aphasia treatment was briefly summarized. Second, studies that directly compare conditions of higher- and lower-intensity treatment for aphasia were reviewed with regard to the inclusion of parameters that contribute to a definition of intensity. In addition to five parameters proposed by 23 and highlighted by 1, total number of sessions was also often documented. The review illustrated the complexity of quantifying the dose of comprehensive treatments that target multiple modalities and utilize a variety of different strategies. Third, data from a study reporting a relationship between intensive computer-based script training and outcomes in aphasia were examined. Results serve to illustrate Bakers contention that intensity alone is insufficient without also considering the active ingredients of the teaching episode. Information about dose, therapeutic inputs, and client acts can lead to better optimization of an intervention.

IMITATE: An intensive computer-based treatment for aphasia based on action observation and imitation

Background: Neurophysiological evidence from primates has demonstrated the presence of mirror neurons, with visual and motor properties, that discharge both when an action is performed and during observation of the same action. A similar system for observation–execution matching may also exist in humans. We postulate that behavioural stimulation of this parietal-frontal system may play an important role in motor learning for speech and thereby aid language recovery after stroke. Aims: The purpose of this article is to describe the development of IMITATE, a computer-assisted system for aphasia therapy based on action observation and imitation. We also describe briefly the randomised controlled clinical trial that is currently underway to evaluate its efficacy and mechanism of action. Methods & Procedures: IMITATE therapy consists of silent observation of audio-visually presented words and phrases spoken aloud by six different speakers, followed by a period during which the participant orally repeats the stimuli. We describe the rationale for the therapeutic features, stimulus selection, and delineation of treatment levels. The clinical trial is a randomised single blind controlled trial in which participants receive two pre-treatment baseline assessments, 6 weeks apart, followed by either IMITATE or a control therapy. Both treatments are provided intensively (90 minutes per day). Treatment is followed by a post-treatment assessment, and a 6-week follow-up assessment. Outcomes & Results: Thus far, five participants have completed IMITATE. We expect the results of the randomised controlled trial to be available by late 2010. Conclusions: IMITATE is a novel computer-assisted treatment for aphasia that is supported by theoretical rationales and previous human and primate data from neurobiology. The treatment is feasible, and preliminary behavioural data are emerging. However, the results will not be known until the clinical trial data are available to evaluate fully the efficacy of IMITATE and to inform theoretically about the mechanism of action and the role of a human mirror system in aphasia treatment.

Communication Partner Training in Aphasia: An Updated Systematic Review

OBJECTIVES To update a previous systematic review describing the effect of communication partner training on individuals with aphasia and their communication partners, with clinical questions addressing effects of partner training on language, communication activity/participation, psychosocial adjustment, and quality of life. DATA SOURCES Twelve electronic databases were searched using 23 search terms. References from relevant articles were hand searched. STUDY SELECTION Three reviewers independently reviewed abstracts, excluding those that failed to meet inclusion criteria. Thirty-two full text articles were reviewed by 2 independent reviewers. Articles not meeting inclusion criteria were eliminated, resulting in a corpus of 25 articles for full review. DATA EXTRACTION For the 25 articles, 1 reviewer extracted descriptive data regarding participants, intervention, outcome measures, and results. A second reviewer verified the accuracy of the extracted data. DATA SYNTHESIS The 3-member review team classified studies using the American Academy of Neurology levels of evidence. Two independent reviewers evaluated each article using design-specific tools to assess research quality. CONCLUSIONS All 25 of the current review articles reported positive changes from partner training. Therefore, to date, 56 studies across 2 systematic reviews have reported positive outcomes from communication partner training in aphasia. The results of the current review are consistent with the previous review and necessitate no change to the earlier recommendations, suggesting that communication partner training should be conducted to improve partner skill in facilitating the communication of people with chronic aphasia. Additional high-quality research is needed to strengthen the original 2010 recommendations and expand recommendations to individuals with acute aphasia. High-quality clinical trials are also needed to demonstrate implementation of communication partner training in complex environments (eg, health care).

Patient-Reported Changes in Communication After Computer-Based Script Training for Aphasia

OBJECTIVE To evaluate changes in patient-reported communication difficulty after a home-based, computer-delivered intervention designed to improve conversational skills in adults with aphasia. DESIGN Delayed treatment design with baseline, preintervention, postintervention, and follow-up observations. SETTING Outpatient rehabilitation. PARTICIPANTS Twenty subjects with chronic aphasia. INTERVENTIONS Sessions with the speech-language pathologist to develop personally relevant conversational scripts, followed by 9 weeks of intensive home practice using a computer program loaded on a laptop, and weekly monitoring visits with the speech-language pathologist. MAIN OUTCOME MEASURE Communication Difficulty (CD) subscale of the Burden of Stroke Scale (BOSS). RESULTS The intervention resulted in a statistically and clinically significant decrease of 6.79 points (P=.038) in the CD subscale of the BOSS during the intervention, maintained during the follow-up period. CONCLUSIONS The findings of this study provide positive albeit preliminary and limited support for the use of a home-based, computer-delivered language intervention program for improving patient-reported communication outcomes in adults with chronic aphasia. Additional research will be required to examine the efficacy and effectiveness of this intervention.

Telerehabilitation, virtual therapists, and acquired neurologic speech and language disorders.

Telerehabilitation (telerehab) offers cost-effective services that potentially can improve access to care for those with acquired neurologic communication disorders. However, regulatory issues including licensure, reimbursement, and threats to privacy and confidentiality hinder the routine implementation of telerehab services into the clinical setting. Despite these barriers, rapid technological advances and a growing body of research regarding the use of telerehab applications support its use. This article reviews the evidence related to acquired neurologic speech and language disorders in adults, focusing on studies that have been published since 2000. Research studies have used telerehab systems to assess and treat disorders including dysarthria, apraxia of speech, aphasia, and mild Alzheimer disease. They show that telerehab is a valid and reliable vehicle for delivering speech and language services. The studies represent a progression of technological advances in computing, Internet, and mobile technologies. They range on a continuum from working synchronously (in real-time) with a speech-language pathologist to working asynchronously (offline) with a stand-in virtual therapist. One such system that uses a virtual therapist for the treatment of aphasia, the Web-ORLA™ (Rehabilitation Institute of Chicago, Chicago, IL) system, is described in detail. Future directions for the advancement of telerehab for clinical practice are discussed.

Dysphagia after head trauma: the effect of cognitive-communicative impairments on functional outcomes.

This article discusses the impact of cognitive-communicative and behavior problems on oral intake. Data on the swallowing outcomes of a group of patients in an acute rehabilitation facility are presented. These data illustrate the relationships among severity of dysphagia, admission and discharge Functional Independence Measure (FIM) scores, admission and discharge cognitive FIM scores and length of stay. Two case studies that describe the effect of cognitive-communicative disorders on dysphagia are provided.