Mieke van de Sandt-Koenderman

Effects of Semantic Treatment on Verbal Communication and Linguistic Processing in Aphasia After Stroke A Randomized Controlled Trial

Background and Purpose— Semantic deficits, deficits in word meaning, have a large impact on aphasic patients’ verbal communication. We investigated the effects of semantic treatment on verbal communication in a randomized controlled trial. Methods— Fifty-eight patients with a combined semantic and phonological deficit were randomized to receive either semantic treatment or the control treatment focused on word sound (phonology). Fifty-five patients completed pretreatment and posttreatment assessment of verbal communication (Amsterdam Nijmegen Everyday Language Test [ANELT]). In an on-treatment analysis (n=46), treatment-specific effects on semantic and phonological measures were explored. Results— Both groups improved on the ANELT, with no difference between groups in overall score (difference, −1.1; 95% confidence interval [CI], −5.3 to 3.1). After semantic treatment, patients improved on a semantic measure (mean improvement, 2.9; 95% CI, 1.2 to 4.6), whereas after phonological treatment, patients improved on phonological measures (mean improvement, 3.0; 95% CI, 1.4 to 4.7, and 3.0; 95% CI, 1.2 to 4.7). Conclusions— No differences in primary outcome were noted between the 2 treatments. Our findings challenge the current notion that semantic treatment is more effective than phonological treatment for patients with a combined semantic and phonological deficit. The selective gains on the semantic and phonological measures suggest that improved verbal communication was achieved in a different way for each treatment group.

High‐tech AAC and aphasia: Widening horizons?

Background: Many people with aphasia are trained to use low‐tech AAC strategies (Alternative and Augmentative Communication) to support communication, but high‐tech communication aids are introduced only incidentally. The factors influencing success and failure of low‐tech AAC are relevant for the development of high‐tech communication aids for aphasia. Aims: To review the state of the art in low‐tech and high‐tech AAC applications for aphasia. Main Contribution: Although there is there is a wealth of knowledge among therapists, there is very little research to support the efficacy of AAC techniques. Many authors stress the heterogeneity of the aphasic population, not only in the characteristics of the aphasia, but also in communicative abilities and needs, cognitive abilities, motivation, and social situation. Therefore, AAC devices should be individualised and “tailor‐made”, taking advantage of residual language skills and communicative strengths. A common problem is that acquired AAC skills are often not used in daily communication. Several factors may play a role, e.g., lack of motivation, inadequate vocabulary, insufficient training, or cognitive or linguistic limitations. So far, functional use of assistive technology has received relatively little attention, but a portable device with ready‐made messages for specific communicative situations appeared to be used in every day life. Conclusions: Computer technology has much to offer for supporting aphasic communication, not only for people with a very severe aphasia, who do not benefit from disorder‐oriented therapy, but also for people with a moderate or mild aphasia. Research into AAC and aphasia, focusing on functional use, is needed in order to build and refine communication aids that are easy to use and can be tailored individually.Background: Many people with aphasia are trained to use low‐tech AAC strategies (Alternative and Augmentative Communication) to support communication, but high‐tech communication aids are introduced only incidentally. The factors influencing success and failure of low‐tech AAC are relevant for the development of high‐tech communication aids for aphasia. Aims: To review the state of the art in low‐tech and high‐tech AAC applications for aphasia. Main Contribution: Although there is there is a wealth of knowledge among therapists, there is very little research to support the efficacy of AAC techniques. Many authors stress the heterogeneity of the aphasic population, not only in the characteristics of the aphasia, but also in communicative abilities and needs, cognitive abilities, motivation, and social situation. Therefore, AAC devices should be individualised and “tailor‐made”, taking advantage of residual language skills and communicative strengths. A common problem is that acquired AAC skills are often n...

Linguistic deficits in the acute phase of stroke.

Abstract.Background and PurposeFor the diagnosis of aphasia early after stroke, several screening tests are available to support clinical judgment.None of these tests enables the clinician to assess the underlying linguistic deficits, i. e. semantic, phonological and syntactic deficits, which provides indispensable information for early therapeutic decisions. The ScreeLing was designed as a screening test to detect semantic, phonological and syntactic deficits. The ScreeLing’s sensitivity, specificity and accuracy in detecting aphasia and semantic, phonological and syntactic deficits were determined.Methods The ScreeLing was validated in an acute stroke population against a combined reference diagnosis of aphasia (aphasia according to at least two of the following measures:ne urologist’s judgment, linguist’s judgment, Tokentestscore). The three ScreeLing subtests were validated in the aphasic population against the presence or absence of a semantic, phonological and/or syntactic deficit according to an experienced clinical linguist.Results From a consecutive series of 215 stroke patients, 63 patients were included. The ScreeLing was an accurate test for the detection of aphasia (0.92),with a sensitivity of 86% and specificity of 96%. Sensitivity of subtests was 62 % for semantics, 54 % for phonology and 42 % for syntax. Specificity was 100 % for semantics and phonology and 80 % for syntax, and accuracy 0.84 for semantics, 0.87 for phonology and 0.64 for syntax.Conclusions The ScreeLing is an accurate test that can be easily administered and scored to detect aphasia in the first weeks after stroke. Furthermore, the ScreeLing is suitable for revealing underlying linguistic deficits, especially semantic and phonological deficits.

Long-term prognosis of aphasia after stroke

Background The long-term functional outcome of aphasia after stroke is uncertain, even though this information is needed as early as possible for adequate patient care and support. This observational prospective study was aimed at predicting functional outcome at 1 year after stroke. Methods We examined linguistic components (ScreeLing) and functional verbal communication (Aphasia Severity Rating Scale, ASRS) in 147 aphasic patients. The ScreeLing was administered at 1, 2 and 6 weeks after stroke; the ASRS at 1 week and 1 year. The relationships between linguistic, demographic and stroke characteristics, and good functional outcome at 1 year (ASRS 4 or 5) were examined with logistic regression analyses. Results The baseline linguistic components (ie, semantics, phonology and syntax) were significant predictors (p<0.001) for 1-year outcome in univariable analyses. In multivariable analysis, these variables explained 46.5% of the variance, with phonology being the only significant predictor (p=0.003). Age, Barthel Index score, educational level and haemorrhagic stroke were identified as other significant predictors of outcome. A prognostic model of these five baseline predictors explained 55.7% of the variance. The internally validated area under the receiver operating characteristic curve (AUC) was 0.89, indicating good predictive performance. Adding the degree of phonological recovery between 1 and 6 weeks after stroke to this model increased the explained variance to 65% and the AUC to 0.91. Conclusions The outcome of aphasia at 1 year after stroke can be predicted in the first week by the phonology score, the Barthel Index score, age, educational level and stroke subtype, with phonology being the strongest predictor.

Melodic Intonation Therapy: Present Controversies and Future Opportunities

This article describes the state of the art of Melodic Intonation Therapy (MIT), a structured aphasia therapy program using the melodic aspects of language (intonation, rhythm, and stress) to improve language production. MIT was developed in the 1970s and is still used worldwide. Nevertheless, we argue that many questions crucial for the clinical application of MIT are still unanswered. First, a review of MIT effect studies is presented showing that evidence from well-designed group studies is still lacking. It is also unclear which aspects of MIT contribute most to its therapeutic effect and which underlying neural mechanisms are involved. Two cases are presented illustrating unsolved questions concerning MIT in clinical practice, such as candidacy and the best timing of this therapy.

A computerised communication aid for people with aphasia

Purpose. To develop a portable computerised communication aid for aphasic people to support communication in everyday life. Method. A multidisciplinary team of aphasiologists, augmentative and alternative communication specialists, speech and language therapists and technicians developed a portable, modular system, PCAD (portable communication assistant for people with dysphasia), running on a commercially available handheld computer. The system was tested in a multiple case study. Aphasia therapy services In the UK, Portugal and The Netherlands referred 28 people with aphasia, who were considered eligible for a computerised communication aid. Participants were trained following a protocol and used the device in self-chosen real life settings. Results. Six of the 28 selected aphasic patients decided not to test the device; 22 participated in the training. All 22 learned to operate the aid, 17 used it functionally, in everyday life. Five people did not use the aid outside the therapy room, although they were able to operate the aid and to use it in role play. These unsuccessful clients were younger, and tended to have a shorter duration of the aphasia. Conclusions. Carefully selected aphasic patients may benefit from a computerised communication aid, using it functionally in everyday communicative settings.

The occurrence of paraphasias in the spontaneous speech of children with an acquired aphasia

Two children with an acquired aphasia were observed during the recovery process. In the spontaneous speech, paraphasias belonging to different categories, such as neologisms, verbal paraphasias, and literal paraphasias, were found. Especially with regard to neologisms the time of investigation was very important. In addition, one child with a phonemic jargon aphasia and one child with a fluent aphasia and empty speech were observed. These observations implicate a modification of the current clinical picture of childhood aphasia. Some aspects are discussed in relation to adult aphasia.

Nonlinguistic Cognitive Impairment in Poststroke Aphasia: A Prospective Study

Background and objectives. Information on cognitive impairment in aphasic patients is limited. Our aim was to investigate the prevalence and course of nonlinguistic cognitive impairments in the first year after stroke and their association with aphasia and functional outcome. Methods. We included 147 patients with acute aphasia. At 3 months and 1 year, we assessed cognition with a nonlinguistic cognitive examination including abstract reasoning, visual memory, visual perception and construction, and executive functioning. We assessed language with a verbal communication rating (Aphasia Severity Rating Scale), the ScreeLing (a linguistic-level screening test), and the Token Test. We evaluated functional outcome with the modified Rankin scale and registered the use of antidepressants. Results. In total, 107 (88%) patients had impairments in at least one nonlinguistic cognitive domain at 3 months and 91 (80%) at 1 year. The most frequently observed impairment concerned visual memory (83% at 3 months; 78% at 1 year) and the least frequent visual perception and construction (19% at 3 months; 14% at 1 year). There was improvement on all cognitive domains including language, except for abstract reasoning. Patients with persisting aphasia had lower cognitive domain scores, worse functional outcome, and were more often depressed than patients who had recovered from aphasia. Conclusions. Standard nonlinguistic cognitive examination is recommended in aphasic stroke patients. Nonlinguistic cognitive impairments are common and associated with poor functional outcome and depression, especially in patients with persisting aphasia.

Advanced Magnetic Resonance Neuroimaging of Language Function Recovery After Aphasic Stroke: A Technical Review

Two advanced magnetic resonance neuroimaging techniques, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI), have recently made their way into clinically oriented research and hold great promise to study the brains adaptive changes of function and structure after aphasic stroke, respectively. Such functional and structural neuroplasticity is thought to underlie the recovery of language function, occurring spontaneously and/or in the context of therapeutic intervention. With fMRI, brain activity can be visualized. Spontaneous brain activity, present in multiple brain networks, is measured with resting-state fMRI and language-related brain activity by having the subject perform a language task during scanning (task-based fMRI). With DTI the major white matter tracts, such as the dorsal and ventral language pathways and the commissural fibers, can be visualized and quantified. Both techniques are entirely noninvasive and thus offer the unique opportunity to perform multiple assessments within the same subject. To gain more insight in functional and structural neuroplasticity after aphasic stroke, advanced magnetic resonance neuroimaging studies in specific patient populations, at several stages after stroke and in the course of language recovery, are needed. Such studies will help to clarify the influence of the many factors that play a role in the recovery of language function and are thus vital to further the development of aphasia therapy. Application of these techniques in aphasic stroke patients, however, is not without challenge. The purpose of this article is to discuss the methodologic challenges of fMRI and DTI in the assessment of language recovery after aphasic stroke.

Screening tests for aphasia in patients with stroke: a systematic review

Aphasia has a large impact on the quality of life and adds significantly to the costs of stroke care. Early recognition of aphasia in stroke patients is important for prognostication and well-timed treatment planning. We aimed to identify available screening tests for differentiating between aphasic and non-aphasic stroke patients, and to evaluate test accuracy, reliability, and feasibility. We searched PubMed, EMbase, Web of Science, and PsycINFO for published studies on screening tests aimed at assessing aphasia in stroke patients. The reference lists of the selected articles were scanned, and several experts were contacted to detect additional references. Of each screening test, we estimated the sensitivity, specificity, likelihood ratio of a positive test, likelihood ratio of a negative test, and diagnostic odds ratio (DOR), and rated the degree of bias of the validation method. We included ten studies evaluating eight screening tests. There was a large variation across studies regarding sample size, patient characteristics, and reference tests used for validation. Many papers failed to report on the consecutiveness of patient inclusion, time between aphasia onset and administration of the screening test, and blinding. Of the three studies that were rated as having an intermediate or low risk of bias, the DOR was highest for the Language Screening Test and ScreeLing. Several screening tools for aphasia in stroke are available, but many tests have not been verified properly. Methodologically sound validation studies of aphasia screening tests are needed to determine their usefulness in clinical practice.