Lynn M. Maher

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.

Ecological implications of limb apraxia: evidence from mealtime behavior.

Humans learn skilled acts in order to effectively interact with their environment. A loss of the ability to perform skilled acts is termed apraxia. Apraxia has been thought to be of theoretical interest, but the ecological implications of apraxia are controversial and have not been fully studied. We examined ten patients with unilateral left hemisphere cerebral infarctions (eight of whom were apraxic) and compared their mealtime eating behavior to a group of neurologically normal, age-matched controls. The stroke patients were less efficient in completing the meal. They made more action errors and were less organized in the sequencing of mealtime activities. Because the patients made more errors while using tools than when performing nontool actions, their deficit could not be accounted for by an elemental motor deficit. A positive relationship was found between mealtime action errors and the severity of apraxia. These findings suggest that limb apraxia may adversely influence activities of daily living.

Behavioral and neurophysiologic response to therapy for chronic aphasia.

UNLABELLED Breier JI, Juranek J, Maher LM, Schmadeke S, Men D, Papanicolaou AC. Behavioral and neurophysiologic response to therapy for chronic aphasia. OBJECTIVE To characterize the relationship between neurophysiologic changes in the brain and behavioral response to constraint-induced language therapy (CILT) by using magnetoencephalography (MEG). DESIGN Case series. SETTING Medical school. PARTICIPANTS Patients (N=23) with chronic aphasia after first-time unilateral stroke in the left hemisphere. INTERVENTIONS Constraint-induced language therapy administered for 3 hours 4 times per week for 3 weeks. Language testing and functional imaging during a language comprehension task using MEG before, immediately after, and 3 months after CILT with a subgroup of patients undergoing additional MEG scanning and language testing 3 weeks before CILT. MAIN OUTCOME MEASURES The percent of correct information units and the number of late dipoles normalized to total activation. RESULTS Three patterns of behavioral and neurophysiologic response to CILT were identified. Patients with significant improvement in language immediately after CILT who lost these gains at follow-up had greater right hemisphere activation than other patients at all MEG scanning sessions. Patients with significant improvement in language immediately after CILT who maintained these gains at follow-up exhibited an increase in left temporal activation after CILT, whereas patients who did not exhibit significant improvement in language after CILT exhibited comparably greater activation in left parietal areas. CONCLUSIONS Results suggest that although the right hemisphere may support recovery of language function in response to therapy, this recovery may not be stable, and some participation of perilesional areas of the left hemisphere may be necessary for a stable behavioral response.

Constraint induced language therapy in early aphasia rehabilitation

Background: Constraint induced language therapy (CILT) focuses on improving acquired expressive language deficits after stroke by applying intensive, use-dependent treatment with constraint to spoken verbal expression. Most CILT research has utilised individuals with chronic aphasia, and previous results indicated improvement on the language assessments after intervention that was largely retained at follow-up. Aims: The purpose of this study was to explore the applicability and outcome of a programme of CILT in individuals in the early phase of recovery from aphasia (1–2 months post onset) in an inpatient rehabilitation hospital setting. Methods & Procedures: A 10-day/3 hours a day pre–posttest CILT intervention case series was carried out 1–2 months post onset with three Norwegian rehabilitation inpatients with aphasia following left CVA. Procedures involved card activities using high- and low-frequency picture stimuli with communicative relevance at four levels of complexity, either in a small group or one-to-one with a trained SLP. Outcomes & Results: Results suggested an overall improvement on the language assessments post CILT intervention, as well as at the follow-up. A greater degree of improvement in performance on expressive speech tasks compared to receptive and written tasks suggested a treatment-specific effect of CILT for early aphasia rehabilitation. Participant evaluation of the CILT intervention reflected positive feedback for the treatment experience and satisfaction with individual gains. Challenges in the application of CILT to this phase of recovery were the need to accommodate the demands of the inpatient rehabilitation setting and the decreased stamina of the participants. Conclusions: The results of this study support the applicability of CILT in early aphasia rehabilitation, with some modifications of the original protocol.

Spatial characteristics of thematic role representation

Humans use language to describe actions by mapping the thematic roles of agent (doer of actions) and patient (recipient of actions) on the grammatical categories of subject and object. The extent to which thematic roles can be conceptualized independent of language is not known. If nonlinguistic conceptualization of thematic roles is possible, then representation of these roles would evidence nonlinguistic characteristics. Motivated by observations in an aphasic man, we wished to learn if thematic roles are conceptualized spatially. Normally subjects were asked to draw stick figures depicting the thematic roles of agent and patient. They demonstrated a systematic spatial bias in locating agents to the left of where they located patients. This bias, somewhat mitigated by ordering effects of motor output and auditory input, was brought into clearest focus when subjects depicted thematic roles in a context stripped of surface sentential form. These data imply that, in their nascent form, the thematic roles of agent and patient are spatially represented prior to being projected on grammar.

Changes in Language-specific Brain Activation after Therapy for Aphasia using Magnetoencephalography: A Case Study

A patient with chronic aphasia underwent functional imaging during a language comprehension task using magnetoencephalography (MEG) before and after constraint induced language therapy (CILT). In the pre- and immediate post-treatment (TX) scans MEG activity sources were observed within right hemisphere only, and were located in areas homotopic to left hemisphere language areas. There was a significant increase in activation in these areas between the two sessions. This change was not observed in an age-matched patient with chronic aphasia who underwent sequential language testing and MEG scanning across a similar time period without being administered therapy. In the 3-month post-TX scan bilateral activation was observed, including significant activation within the left temporal lobe. The changes in the spatial parameters of the maps of receptive language function after therapy were accompanied by improvement in language function. Results provide support, in the same individual, for a role for both hemispheres in recovery of language function after therapy for chronic aphasia.

Management of Anomia

Abstract Anomia is a complex, commonly occurring symptom of aphasia with different underlying causes. A number of behavioral approaches to rehabilitation of anomia have been described. Some are restitutive in nature and attempt to reactivate lexical-semantic or phonological representations to improve word retrieval. Others are intended to reorganize language functions by engaging alternative cognitive systems to mediate word retrieval or by exploiting residual abilities to circumvent the impairment. A better appreciation of the characteristics of an individual’s naming deficit may assist the clinician in selecting appropriate interventions for restitution or substitution of function in the management of this disorder.

Functional imaging before and after constraint-induced language therapy for aphasia using magnetoencephalography

Five patients with chronic aphasia underwent functional imaging using magnetoencephalography (MEG) before and after constraint-induced language therapy (CILT). Patients who responded well to CILT exhibited a greater degree of late MEG activation in posterior language areas of the left hemisphere and homotopic areas of the right hemisphere prior to therapy than those who did not respond well. Response to CILT, however, was positively correlated with the degree of pre-therapy MEG activity within posterior areas of the right hemisphere only on an individual basis.

Spatiotemporal patterns of language-specific brain activity in patients with chronic aphasia after stroke using magnetoencephalography

Six participants with chronic aphasia secondary to first-ever ischemic stroke within the middle cerebral artery (MCA) distribution of the left hemisphere and six neurologically intact controls of similar age were given a running recognition memory task for words while the magnetic flux normal to the scalp surface was measured with a whole-head neuromagnetometer. This task had been previously shown to be valid for the localization and lateralization of brain activity specific to receptive language function. As expected, patients exhibited relatively decreased activation in areas known to be involved in receptive language function, including superior temporal gyrus (STG) in the left hemisphere, as well as increased activation of areas outside of the left STG that might potentially support language function. Decreased activation within left STG was associated with a reduction in receptive language in patients, as was increased activation outside of left STG. Results support hypotheses suggesting that peri-lesional areas outside premorbid language areas may assume receptive language function after aphasia secondary to stroke, but that better recovery occurs when putative premorbid language areas are able to normalize.

Changes in maps of language activity activation following melodic intonation therapy using magnetoencephalography: Two case studies

Two patients with chronic expressive aphasia underwent two blocks of melodic intonation therapy (MIT) each. Maps of language-specific neurophysiological activity were obtained prior to and after each MIT block during a covert action naming task using magnetoencephalography. Both patients exhibited increased left hemisphere activation after MIT. The patient who responded positively to therapy exhibited decreasing activation within areas of the right hemisphere homotopic to left hemisphere language areas compared to baseline after both blocks of MIT. In contrast, the patient who did not show improvement after therapy exhibited increasing activation in these areas of the right hemisphere after therapy. Results are consistent with hypotheses that melodic intonation therapy acts through promotion of left hemisphere activation.