Marjorie Nicholas

Language Rehabilitation in Chronic Aphasia and Time Postonset. A Review of Single-Subject Data

Background and Purpose— This article is a comprehensive review of aphasia treatment studies for the purpose of investigating the relationship between time postonset of aphasia and response to treatment for aphasia in chronic patients at ≥1 year after symptom onset. Methods— Studies that demonstrated treatment response (defined as a measurable change in task performance compared with a control task performance) through the use of single-subject design methodologies on measures of verbal output or auditory comprehension were selected. Individual subject data were extracted from the 23 studies that met criteria identifying the subjects as those who received direct continuous therapy for spoken language deficits and whose changes in response to therapy were measurable. Percent of maximum possible change was used as a measurement of outcome. Results— Nonparametric correlation statistics (Spearman &rgr;) and comparisons of group means (Kruskal–Wallis) were used to compare the relationship between time postonset and improvement. Time postonset at which treatment was initiated did not correlate with response to treatment. No significant differences in response to treatment were found between groups of patients according to times postonset. Conclusions— Time postonset is not related to response to treatment for aphasia in patients >1 year postonset of aphasia.

The relation between language, non-verbal cognition and quality of life in people with aphasia

ABSTRACT Background: People with aphasia (PWA) display a variety of non-linguistic cognitive profiles of impairments and strengths that interact not only with their specific profiles of language impairments and strengths, but also their potential for positive response to communication treatment, and potentially to their quality of life (QOL) post stroke. While researchers have investigated how severity of aphasic language impairment affects QOL, very few studies have examined how impairments in non-verbal cognition in PWA affect their QOL. Aims: The specific aims of this project were to further explore the relation between non-verbal cognitive and linguistic abilities in a group of PWA who were in the chronic phase post onset and to evaluate how impairments in these two domains related to QOL. Methods & Procedures: A group of 28 individuals with aphasia were tested with a language battery, a non-verbal cognition battery and an aphasia-friendly measure of QOL. The statistical analysis used an all-possible-subsets regression analysis. Outcomes & Results: Results indicated that non-verbal cognitive impairments predicted three times the variance on a measure of QOL than language impairments did. Non-verbal cognitive tasks that emerged as predictors included a trails task, a visual memory task, and a maze completion task. Results also indicated that 20 participants of the sample of 28 showed congruence of severity level across the domains of language and non-verbal cognition. Conclusions: Non-verbal cognitive impairments may significantly affect QOL in people with aphasia and should not be overlooked as potentially important predictors.

People with aphasia using AAC: are executive functions important?

ABSTRACT Background: Many people with aphasia (PWA) who are introduced to augmentative and alternative communication (AAC) struggle to become effective and independent users of AAC. Aims: In this article, we discuss how impairments of executive functioning (EF) might be expected to interact with ability to use AAC effectively. We also review the research literature that has investigated the relationship between EF and response to AAC treatment in aphasia. Assessment tools that may be useful in predicting successful use of AAC by PWA are also discussed. Main Contribution: Results from the few available studies are mixed with respect to the importance of EF to successful AAC use. At present, there is a paucity of research directly investigating which aspects of EF might be the best predictors for response to treatment to learn AAC, although some researchers have reported that EF tasks designed to measure cognitive flexibility (shifting) appear to have some predictive utility. Conclusions: Using terminology from two published models of EF, we suggest that executive attention, which includes working memory, as well as updating, shifting and inhibiting, are all necessary when using AAC for successful communication. This perspective is one that should receive more attention in clinical practice and when designing research on use of AAC by PWA.

Understanding of observed video action events by people with aphasia

Background: Many people with aphasia show preservation of areas of cognition that do not rely on language comprehension or expression. However, several studies have reported on individuals, who have difficulty processing nonverbal events, i.e., they do not seem to make inferences about the outcome of observed events as easily as people without language impairment. The relative frequency of this deficit in those with aphasia is not well understood, however, because most studies have focused on only one or two individuals. Aims: The aims of the current study were: (1) to investigate how frequently a deficit in nonverbal event processing would be found in a group of 28 individuals with chronic aphasia and (2) to explore the relationship between this deficit and standardised measures of language and nonverbal cognition. Methods & Procedures: The Role Video and a battery of standardised language and nonverbal cognition assessments were given to 28 participants with chronic aphasia representing a range of aphasia severities and syndromes, and to 10 age-matched healthy controls. The Role Video, an assessment created by Marshall, Pring, and Chiat (1993b), consists of 32 short videos each lasting approximately 5 seconds. The task is to watch each video and judge the outcome of the observed event by selecting a picture from a set of three. No language is spoken in the videos; nor is language required to respond. Outcomes & Results: Results indicated that the group of PWA performed significantly worse on the Role Video than the healthy control group. Using a criterion of more than two standard deviations below the mean of the controls as indicative of impairment, a surprisingly large portion of the sample with aphasia (54%) had impaired event processing. The data analysis indicated deficits in event processing were related to impairments in language and nonverbal cognition. Conclusions: Impaired event processing may be more common in aphasia than previously believed. This impairment has implications for treatment of aphasia, given that many communicative interactions require retelling of events either verbally or via augmentative means.

Modified Berg Balance Scale: making assessment appropriate for people with aphasia

Abstract Objective: Modifying assessments for people with aphasia has the potential to increase the validity of healthcare assessments across professional domains. This pilot study addressed the challenges of giving people with aphasia the power to fully participate in the assessment process. The study aimed to investigate the feasibility of using an aphasia-modified version of the Berg Balance Scale (BBS), a physical therapy assessment tool to quantify dynamic sitting and standing balance. Method: The study compared how people with aphasia performed on the original BBS to an aphasia-modified version (MBBS), created for this study. We examined the relationship between auditory comprehension scores and balance performance of 15 participants with chronic aphasia and three control participants. We tested the hypothesis that individuals with aphasia would perform higher on the MBBS rather than the BBS, thus more closely approaching a score reflective of their true physical abilities. Results: Overall people with aphasia performed significantly better on the MBBS than the BBS, indicating that at least some portion of their performance difficulty was likely due to poor auditory comprehension of test instructions rather than true balance difficulty. Conclusion: Implications of this study suggest that modifying assessments, such as the BBS, by reducing linguistic complexity and adding visual and written cues along with modeling and repetition has the potential to increase the validity of healthcare assessments for individuals with aphasia.

Effects of phonological neighbourhood on the treatment of naming in aphasia

Background: Phonological treatments to improve naming ability in aphasia focus on re-strengthening connections within the phonological system. Nonetheless, the efficacy of phonological treatments is still being explored with particular consideration of cognitive neuropsychological perspectives. Clinicians may also need to consider lexical factors that interact with the word retrieval process. Researchers have shown that phonological neighbourhood density influences normal language recognition and production, but limited evidence exists for how phonological neighbourhoods may affect the treatment of word retrieval deficits in individuals with aphasia. Aims: The present study explored if manipulating the emphasis on phonological neighbourhood during treatment has an effect on naming ability, particularly in an individual with predominantly phonologically based deficits. We hypothesised that training front- and end-matched words in a condition that emphasised phonological neighbourhood would result in greater naming improvements than training front- and end-matched words in a condition that does not emphasise neighbourhood. Methods & Procedures: In this case study, participant AH had a moderate phonologically based word naming deficit following a stroke. He produced phonemic paraphasias and neologisms in spontaneous speech and other spoken word production tasks. In treatment, AH was asked to name triplets of pictures of items that were phonologically related, sharing initial or final phonemes, or unrelated. Items were from either high- or low-density phonological neighbourhoods. High-density items were trained largely in the context of neighbours, therefore emphasising neighbourhood. Low-density items were not trained within a condition that emphasise neighbourhood. The treatment was administered for 9 weeks (27 sessions), with each condition, front-matched, end-matched and unrelated, trained for 8 consecutive sessions. AH’s naming accuracy on training words was assessed using a basic withdrawal design with three probe naming tests during the treatment phase and at 1-month post-therapy. Naming accuracy was also recorded during treatment sessions. Outcomes & Results: Front-matched words, in a condition that emphasises phonological neighbourhoods, had the greatest treatment effects, with a medium effect size when comparing pre- versus post-measures. A small treatment effect was observed for front-matched items where neighbourhood was not emphasised. Conclusions: Results suggest that front-matched triplets trained within a condition that emphasises phonological neighbourhoods may lead to the greatest treatment effect. Clinicians should be aware that stimulus parameters, such as phonological neighbourhood, may interact with the effectiveness of treatment protocols.

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.

Speak along without the song: what promotes fluency in people with aphasia?

ABSTRACT Background: Melodic intonation therapy (MIT) is a widely used treatment for nonfluent aphasia that builds upon a number of musical elements in order to ultimately improve generative language. These include intoning syllables on different pitches, using a metrically regular speech rhythm, and the clinician and patient producing phrases in unison. Studies have investigated which of these musical elements might be the most clinically facilitating, but important differences in methodology and results across studies leave some questions unanswered. In particular, the relative roles of intoning and unison production remain unclear. Aims: The present study examined these elements in isolation and in combination. Methods & Procedures: Twelve people with aphasia (PWA) and 10 control participants sang and rhythmically spoke unfamiliar song lyrics in unison with a recording and by themselves. A subset of eight of the PWA returned for post-hoc testing to evaluate singing familiar lyrics from memory, and propositional speech. Across all tasks, productions were evaluated for syllable accuracy. Outcomes & Results: On average, PWA benefited from unison over solo production and from rhythmic speech over singing when repeating unfamiliar lyrics. They did show a benefit of singing when producing familiar lyrics from memory, but this post-hoc task did not control for syllable duration or task order. Within-group correlations indicated that those with more severe apraxia of speech, worse single-word auditory comprehension, and poorer repetition ability benefited the most from unison production. Those with better sentence-level auditory comprehension and poorer performance on a perceptual rhythm test tended to benefit more from singing compared to rhythmically speaking unfamiliar lyrics. Conclusions: Unison production is an important element for promoting fluency in many PWA, and perhaps especially for those for whom MIT is considered an appropriate treatment option. However, some candidates for MIT are hindered by the inclusion of even moderately complex melodic information, indicating that this factor should be considered when customizing or adapting the therapy. Finally, PWA who show a striking improvement in fluency when singing familiar songs will not necessarily benefit from singing when the aim is to produce new lyrics or propositional content.