Can impairment-focused therapy change the everyday conversations of people with aphasia? A review of the literature and future directions

Background: The ultimate goal in any programme of aphasia rehabilitation is that behaviours targeted in therapy will generalise to everyday use for people with aphasia (PWA). The pervasiveness of conversation in everyday life has undoubtedly contributed to the recent interest in aphasiology regarding how we facilitate, and capture evidence of, change in conversation following therapy. Given the rich nature of conversation data, various analytical approaches have been utilised within impairment-focused therapy studies; however, much of this work has been carried out in isolation from other methodologies such as conversation analysis (CA)—a field which has historically concerned itself with conversation data. The result is a growing literature base which is dispersed in nature. For clinicians who are faced with the daily challenge of therapeutic management for a diverse population of PWA the literature on generalising therapy gains to everyday conversation may be too unwieldy to be of benefit to current clinical practice.

Aims: This paper aims to synthesise and critically review key papers from impairment-focused studies which have investigated the impact of therapy on the conversations of PWA. For the purposes of this review, conversation is defined as a dialogue between the person with aphasia and a conversation partner.

Main Contribution: First, the motivation to investigate conversation within aphasia assessment is discussed, with consideration of how conversation differs from, but ultimately complements, other forms of language assessment. Following this, five impairment therapy studies will provide a platform for discussion of methodological issues and analytical approaches relating to conversation data. Finally, consideration is given to how researchers and clinicians may build on current literature to develop the use of conversation as an outcome measure in aphasia intervention. Where appropriate, insights are drawn from interaction-focused therapy studies regarding the collection and analysis of conversation data.

Conclusions: There is emerging evidence that impairment-focused therapy can impact on the conversations of PWA. While these early findings are promising, investigations have been limited to naming therapies and the methods of data collection used have implications for ecological validity. Incorporating particular elements of interaction-focused approaches may help to inform data collection, investigations of therapy outcome, and issues of candidacy for specific treatments. Furthermore, combining therapeutic and analytical approaches is likely to be more closely akin to the clinical reality of aphasia intervention, where clinicians are likely to use all resources at their disposal in the rehabilitation of a speaker with aphasia.     

Investigating the sub‐processes involved in the production of thematic structure: An analysis of four people with aphasia

Background: Schwartz (1987) suggested that three discrete sub‐processes may be involved in the production of the thematic structure of sentences. These are: (1) The retrieval of the semantic representations of the main lexical items; (2) The specification of the predicate argument structure (PAS); and (3) The assignment of the lexical items to thematic roles within the PAS. There has been no comprehensive investigation of the three aspects of processing in the performance of individual people with aphasia. Aims: This study aimed to investigate the presence of the three sub‐processes by determining whether they can be differentially impaired in aphasia. Methods & Procedures: Four people with aphasia (GW, JM, KD, and TJ) who had apparent difficulties in producing thematic structure were included in the study. They presented with similar surface symptoms in connected speech: a high percentage of single phrases, limited production of complex three‐argument structures, and the omission of obligatory arguments. Their performance on various tests of single word and sentence processing was compared to that of normal control subjects and the pattern of errors analysed. Outcomes & Results: The clients presented with different patterns of impaired and retained performance and different patterns of error. This suggested that different underlying impairments were responsible for their poor production of thematic structure. All four clients presented with some verb retrieval difficulties, although only GW and TJ's deficits were of a semantic nature. TJ also had difficulty understanding and retrieving nouns, but when given the words showed awareness of the PAS and could assign thematic roles appropriately. JM presented with a specific difficulty specifying the PAS, and KD had a specific difficulty with thematic role assignment. GW had difficulties both with the specification of PAS and thematic role assignment. Conclusions: The results of the study suggest that difficulties in producing the thematic structure of sentences may be a consequence of different underlying impairments. The different impairments provide some support for the sub‐processes suggested by Schwartz. The same surface symptoms in connected speech can be a consequence of different underlying impairments and thus if therapy is be targeted at the impaired process, treatment needs to be preceded by detailed assessment.     

Aphasia blog talk: How does stroke and aphasia affect the carer and their relationship with the person with aphasia?

Background: Carers of stroke survivors with aphasia are at risk of experiencing negative bio-psychosocial consequences and reduced quality of life. So far, in aphasia studies, this has mainly been explored through qualitative interviews and questionnaires. Unsolicited first-person narratives in the form of blogs offer a novel and rich source of data to examine how stroke and aphasia affect the carer and their relationship with the person with aphasia.

Aims: This study explored how carers of people with aphasia perceive their roles and responsibilities; it also examined the consequences of carrying out these carer roles and duties, in terms of both the carer’s own well-being and their relationship with the person with aphasia; furthermore, it investigated facilitative factors in their adaptation to the carer role.

Methods & Procedures: Publically available blogs written by carers of aphasic stroke survivors, which included information on how stroke and aphasia affect the carer and their relationship with the person with aphasia, were analysed using the Framework Method.

Outcomes & Results: The search resulted in nine carer blogs. The number of posts per blog ranged from 13 to 241. For blogs containing over 90 posts, the first and last 30 relevant posts were collected and analysed. New roles and extra responsibilities identified by participants included having to act as therapists, nurses, counsellors, and administrators and carrying out tasks usually assigned to the other person in the relationship. The extra tasks and duties impacted on the carers’ quality of life and their relationship with the person with aphasia in negative ways, such as leading to physical and mental exhaustion, health issues, feeling lonely, and resentful of their circumstances; however, participants also identified positive changes such as new closeness, new appreciation of life, and pride in achievements. A variety of strategies emerged from the data that helped carers adjust to their new roles. Strategies included positive reframing, allocating time to oneself, and seeking support from family and friends. The activity of blogging was also mentioned as having beneficial effects on the carers’ well-being.

Conclusions: The study provides further evidence for the specific challenges faced by carers of people with stroke and aphasia; it thus confirms the importance of addressing carer related needs in intervention and considering psychosocial well-being for both the carer and the person with aphasia.     

Barriers and facilitators to using the CommFit™ smart phone app to measure talk time for people with aphasia

Background: The use of mobile technology in aphasia rehabilitation is an emerging area of research. CommFit? is a smart phone application which was developed according to aphasia-friendly guidelines to measure the talk time of people with aphasia. Presently, the ease-of-use of CommFit? for people with aphasia has not been investigated, and there is little research on the barriers and facilitators to using mobile technology for this population.

Aims: The aim of this study was to describe the barriers and facilitators experienced by people with aphasia while using CommFit?.

Methods &; Procedures: Twelve people with aphasia used the CommFit? system-app, iPhone and BlueTooth headset, to measure their talking time for 14 days. The Western Aphasia Battery-Revised Aphasia Quotient was used to determine aphasia severity. During the initial training session and data collection period, field notes were taken by researchers. At the end of the data-collection period, participants completed an ease-of-use rating scale and participated in semi-structured interviews on the barriers and facilitators to using the CommFit? system.

Outcomes &; Results: Field notes and data from semi-structured interviews identified eight barriers; physical and language impairments related to stroke, other physical barriers not related to stroke, time constraints, unfamiliarity with technology, social attitudes, design of the technology and technology malfunction. Facilitators included support from researchers, support from other people, app design and use of the manual. On the ease-of-use rating scale, steps involving the headset were rated as less usable than other steps involved in using the CommFit? system. However, all steps had mean scores indicating that they were “easy to use” or “very easy to use”. Spearman correlations indicated that there was no significant relationship between ease-of-use ratings and aphasia severity. However, there was a significant negative correlation between age and ease-of-use rating of “pairing the headset” (r = ?0.8173, p = 0.013).

Conclusions: The results of this study identified barriers to using mobile technology, many of which were not connected to the participants’ stroke-related impairments. It also identified several facilitators which should be capitalised on when using mobile technology with this population. Last, results indicated that the BlueTooth headset was not a highly usable component of the CommFit? system, especially for older users. This will be addressed in future research on the app.     

The effectiveness of aphasia‐friendly principles for printed health education materials for people with aphasia following stroke

Background: Provision of health information to people with aphasia is inadequate. Current practice in providing printed health education materials to people with aphasia does not routinely take into consideration their language and associated reading difficulties. Aims: This study aimed to investigate if people with aphasia can comprehend health information contained in printed health education materials and if the application of aphasia‐friendly principles is effective in assisting them to comprehend health information. It was hypothesised that participants with aphasia would comprehend significantly more information from aphasia‐friendly materials than from existing materials. Other aims included investigating if the effectiveness of the aphasia‐friendly principles is related to aphasia severity, if people with aphasia are more confident in responding to health information questions after they have read the aphasia‐friendly material, if they prefer to read the aphasia‐friendly brochures, and if they prefer to read the brochure type that resulted in the greatest increase in their knowledge. Methods & Procedures: Twelve participants with mild to moderately severe aphasia were matched according to their reading abilities. A pre and post experimental design was employed with repeated measures ANOVA (p <. 05) used to investigate the effectiveness of the aphasia‐friendly principles. Outcomes & Results: While participants with aphasia comprehended health information from the existing printed education materials, participants comprehended 11.2% more information from materials that had an aphasia‐friendly format. No significant correlation between aphasia severity and aphasia‐friendly effectiveness was found. Participants were more confident in answering questions after they had read the aphasia‐friendly brochures. A clear preference for aphasia‐friendly brochures was not found and participants did not consistently select the brochure type that resulted in the greatest increase in their health knowledge. Conclusions: This preliminary investigation has found that aphasia‐friendly material does assist people with aphasia to comprehend health information. The benefits of providing aphasia‐friendly information have many clinical applications that extend beyond the provision of health information. The application of aphasia‐friendly principles to all written materials could prove beneficial in removing some of the barriers people with aphasia face in trying to comprehend written materials. In addition, this research has highlighted that a greater understanding of people with aphasia's reactions to aphasia‐friendly materials and also the social impact of providing aphasia‐friendly information is required. Future research, that incorporates a qualitative research approach, will add valuable insight to these topics.     

Developing an evidence‐base for accessibility for people with aphasia

Background: Discrimination on the basis of disability is prohibited in many countries and therefore research on communication accessibility for people with aphasia has become a priority.

Aims: The aim of this paper is to summarise and discuss the results of a series of research studies, carried out in one Centre, into accessibility issues for people with aphasia, focusing on the accessibility of community environments and the accessibility of information.

Main Contribution: When asked about the accessibility of the community generally, people with aphasia reported both physical and societal barriers and facilitators, as well as barriers and facilitators related to other people. Many people with aphasia still do not receive written health information about aphasia and, when they do, the information is often written at a level too high for them to read. In terms of the accessibility of written information on websites about aphasia, high‐quality websites may not be easily accessible to people with aphasia. For accessible websites to be delivered, the involvement of people with aphasia is paramount.

Conclusions: There are three common themes emerging from this series of research studies. First, accessibility is an important and often emotive issue for people with aphasia. Second, people with aphasia are marginalised by a communicatively inaccessible society. Third, there is considerable diversity among people with aphasia about their perceptions of the barriers and facilitators to communication in the community.     

Effectiveness of a vocabulary data file,encyclopaedia, and Internet homepages in a conversation‐support system for people with moderate‐to‐severe aphasia

Background: In order to facilitate conversation for people with moderate‐to‐severe aphasia, a conversation‐support system has been developed. This system consists of three electronic resources: a vocabulary data file, an encyclopaedia, and homepages on the Internet. The vocabulary data file we created contains approximately 50,000 words, mostly consisting of various proper names, which are classified into 10 categories. These words function as keywords in conversation.

Aims: To evaluate the effectiveness of the three resources in eliciting new information from people with aphasia.

Methods & Procedures: Fifteen people with non‐fluent and moderate‐to‐severe aphasia participated in the experiment. Participants conversed with their communication partners about four topics under use and non‐use conditions. Under the use condition, partners showed pages from one of the three resources on the screen of a personal computer. Participants were asked to select words on the pages, or use other modalities (verbal or nonverbal), to answer questions. Three evaluators gave points for information conveyed correctly.

Outcomes & Results: Comparison of the points between the use and non‐use conditions showed that significantly more information was conveyed when the vocabulary data file was used. On the other hand, the amount of points did not increase in the use condition using the encyclopaedia or homepages.

Conclusions: The vocabulary date file succeeded in eliciting more information from people with moderate‐to‐severe aphasia within a limited timeframe. Presentation of the keyword or proper name lists related to the topics was shown to be a useful conversation resource for people with moderate‐to‐severe aphasia. As for the encyclopaedia and homepages, further research is required to determine whether or not these resources in collaboration with the data file can further facilitate conversation.     

A pre–post intervention study investigating the confidence and knowledge of health professionals communicating with people with aphasia in a metropolitan hospital

Background: Communication partner training (CPT) is a social intervention approach that can be used to educate and train volunteers, family members, significant others and professionals, in addition to providing skills and strategies for people with aphasia (PWA). This body of CPT research extends the current research in the area by implementing CPT with health professionals (HPs) in using PWA as trainers in a sub-acute care setting, but some previous research in acute care setting has primarily focused on caregivers and volunteers in a community setting.

Aims: The aim of this study was to investigate implementing a CPT programme in an Australian metropolitan hospital by training professionals and utilising PWA as a key component of the training to facilitate “real-time” practical skill acquisition.

Method & Procedures: Fifty-two HPs from multidisciplinary teams (allied health assistants, audiology, dietetics, occupational therapy, pharmacy, physiotherapy, social work and nursing staff in a rehabilitation unit) participated in a pre–post intervention study. HPs completed a questionnaire to collect demographic information, identify current knowledge of aphasia-related communication strategies and ascertain their confidence levels (using a 100-mm visual analogue scale) related to interacting with people with communication impairments and list any strategies/resources that could be used as an adjunct to facilitate exchanges with PWA. These open-ended responses were categorised into four main groups using content analysis. The CPT component, adapted from two programmes run by “Connect—Communication Disability Network” in the United Kingdom, consisted of an educational lecture on communicating with PWA given by a speech-language pathologist and a practical conversation with a person with aphasia. The PWA provided “expert” practical feedback to the professionals participating in the training.

Outcomes & Results: HPs reported mean confidence levels of 46.56 mm (SD = 15.71) prior to training and 75.81 mm (SD = 12.16) post-training, t(51) = 12.479 (p < .001). More HPs were able to identify relevant strategies to assist with communication following the training (median total responses = 52, interquartile range [IQR] = 50–52), than prior to the training (median total responses = 15, IQR = 9–38).

Conclusions: The results provide preliminary evidence to suggest that a CPT programme may be an effective method to increase the confidence and knowledge of communication strategies of HPs, in an acute care setting, when interacting with PWA.     

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.     

Patterns of language improvement in adults with non‐chronic non‐fluent aphasia after specific therapies

Background: Recent years have seen a growing number of dysgraphia therapy studies informed by models of the normal writing mechanism (see Beeson &; Rapcsak, 2002 Beeson, P. and Rapcsak, S. 2002. “Clinical diagnosis and treatment of spelling disorders.”. In The handbook of adult language disorders, Edited by: Hillis, A. New York: Psychology Press.  [Google Scholar], for review). Although outcomes from these studies have been encouraging, measures are often confined to clinical tests, leaving it unclear whether everyday writing activities have benefited. This study similarly applied a processing model but was driven from the outset by the everyday writing goal of the aphasic participant.

Aims: The study aimed to explore whether therapy could improve the note‐taking abilities of an aphasic individual. Evaluations aimed to determine whether gains reflected improvements to the writing mechanism and/or the application of writing strategies.

Methods &; Procedures: This is a single‐case therapy study of “Ray”, an individual with chronic aphasia and dysgraphia. Ray's priority for therapy was writing, with the goal of improving his note‐taking abilities for work. Ray's dysgraphia seemed due to a buffer‐level impairment, with length effects and errors of letter deletion, addition, transposition, and substitution. Therapy involved spelling practice and work on writing strategies. The outcome measures showed improvements both in note taking and in writing to dictation.

Conclusions: The results suggested that therapy reduced the effects of Ray's buffer impairment and improved his use of writing strategies. The study demonstrates how model‐based thinking can be integrated with a functional approach in intervention.     

Using resource allocation theory and dual‐task methods to increase the sensitivity of assessment in aphasia

Background: Quantifying the severity of language impairment and measuring change in language performance over time are two important objectives in the assessment of aphasia. The notion of cognitive effort as understood from a resource allocation perspective provides a potentially useful complement to traditional constructs employed in aphasia assessment. Aims: The series of experiments described in this paper used resource allocation theory and dual‐task methodology (1) to assess whether a language comprehension task (Story Retell Procedure) and a visual‐manual tracking task trade performance under dual‐task conditions, and (2) to investigate the potential utility of these methods in clinical assessment of aphasia. In Experiment 1, the validity of a difficulty manipulation of the SRP was investigated. In Experiments 2 and 3, the reliability and validity of the visual‐manual tracking task were evaluated. Experiment 4 investigated whether the two tasks trade performance under dual‐task conditions. Methods & Procedures: In Experiment 1, 20 normal participants listened to and retold stories presented by a normal speaker and speakers with mild, moderate, and severe aphasia. Participants' comprehension performance was measured by calculating the amount of information retold per unit time. In Experiment 2, root mean square (RMS) tracking error data were collected under fixed joystick displacement conditions. In Experiment 3, 20 normal participants performed single‐task tracking across 12 trials at each of three difficulty levels, and performance was evaluated in terms of RMS error. In Experiment 4, three groups of 20 normal individuals performed the tracking task while listening to stories told by the normal speaker and speakers with aphasia. Story retell performance was evaluated between subjects across three tracking difficulty levels and tracking performance was evaluated within subjects across story difficulty (normal, mild, moderate, and severe aphasia). Outcomes & Results: The results of Experiments 1–3 supported the reliability and validity of the difficulty manipulations for the story retell and tracking tasks. In Experiment 4, tracking performance was found to vary significantly across story difficulty, with subjects demonstrating better tracking performance while listening to stories told by a mildly aphasic speaker than during stories told by a speaker with moderate aphasia. There was no effect of tracking difficulty on story comprehension as measured by subsequent story retell performance. Conclusions: The results provide qualified support for both a resource allocation view of language performance in normal individuals and the potential utility of these methods in the assessment of aphasia. These conclusions, however, are mitigated by the finding of only a unidirectional (as opposed to bidirectional) performance trade, and by the fact that the effect of story difficulty on tracking performance was observed across only two levels of aphasia severity.     

Implicit phoneme manipulation for the treatment of apraxia of speech and co‐occurring aphasia

Background: Apraxia of speech (AOS) is a disorder of expressive speech attributed to an impairment at the motor planning and programming phases of speech production. AOS is treated in different ways but the articulatory kinematic approach is usually followed. The intervention described in this study introduces a new approach toward treatment of AOS with aphasia through the use of implicit manipulation of phonemes via rhyming, deletion and alliteration tasks. Theoretical models propose that during lexical retrieval, associated areas responsible for motor planning and the preparation of the utterance are activated. In a similar way, our tasks require a phoneme manipulation that is hypothesised to activate motor planning. The repeated implicit practice of retrieving and internally monitoring sounds in various phonetic contexts may improve the efficiency of the transition between phonological plans and the initial phase of motor planning and the monitoring of that plan. Therefore, if AOS is due to a dysfunction of motor planning, an implicit intervention targeting this phase may improve speech production without the need for overt practice.

Methods and Procedures: This single‐subject multiple baseline intervention used implicit phoneme manipulation tasks in a subject with AOS and mild aphasia. The therapist‐designed computerised program required the subject to perform the implicit practice of rhyming, deletion, and alliteration of phonemes in three sound classes: /?/, /?/, and /s/ clusters in various phonetic contexts. Stimuli were presented on computerised templates requiring the subject to select the target among 3 foils. No overt speech was required however probe word repetitions were necessary to monitor treatment effects.

Outcomes and Results: The effect sizes for the trained words were: /?/ probes d = 4.46, /?/ probes d = 6.02, and /s/ clusters d = 2.54 which represents a small to medium effect for /?/ and /?/. T‐MAC results of 59/87 (68%) at pre‐testing improved to 75/87 (87%) at post‐test (z = 3.08, binomial p < .01, two‐tailed) which suggest generalisation to non‐treatment words. Patterns of change in three probe words over the course of treatment suggest an improvement in speech production. Distortions, disturbed prosody and phonological errors were resolved in these probes by the maintenance session as judged by 5 SLPs.

Conclusions: We conclude that in this participant (1) implicit phoneme manipulation training improved overt speech production; (2) accuracy of trained words, specifically a reduction in sound distortions, phonological errors and improved prosody, were the result of this treatment; and (3) a significant generalisation to non‐treatment words was the result of the intervention.     

Computers in aphasia therapy: Effects and side‐effects

We review published studies on the use of computers in aphasia therapy. Computer‐based treatment seems attractive, especially as it may allow for massed practice. We discuss possible side‐effects. Aphasia rehabilitation must aim at a reduction of handicap. At least one published study described an improvement in functional communication after treatment with a comprehensive programme that included both therapist‐delivered speech‐language therapy and home computer training. It cannot be decided to what extent functional communication‐orientation of the programme, computer use, intensity of treatment, or even other factors contributed to the positive effect, as no control group was included. A randomised controlled trial with adequate control groups and adequate, handicap‐oriented outcome measurements is warranted to evaluate the effectiveness of the computer component and its effect size.