Segmental and prosodic variability on repeated polysyllabic word production in acquired apraxia of speech plus aphasia

Background: McNeil and colleagues argued that individuals with pure apraxia of speech (AOS) have low variability of speech error type and error location within repeated multisyllabic words, compared to individuals with conduction aphasia. While this concept has been challenged, subsequent studies have varied in the stimuli and tasks used.

Aims: Our aim was to re-examine the variability of segmental errors, as well as lexical prosodic errors, using the same stimuli and tasks as used by McNeil and colleagues in a sample of individuals with AOS plus aphasia or aphasia alone. This sample is considered to be clinically relevant given the high concomitance of these disorders.

Methods & Procedures: Participants were 20 individuals with stroke-related AOS plus aphasia and 21 with aphasia alone (APH), with diagnosis based on expert judgments using published criteria. Three consecutive repetitions of 10 polysyllabic words were elicited and variability of error type, error location, and durational stress contrast was measured.

Outcome & Results: Errors were significantly more variable in type and more consistent in location within word for the AOS group than the APH group. The AOS group showed a greater number of errors overall, were less likely to improve production over the three repetition trials, and produced no clear difference in vowel duration across the first two syllables (i.e., durational stress contrast) across repetitions. The measure of durational stress contrast was a stronger predictor of AOS presence than the measures of error variability.

Conclusions: The divergence of our findings from previous work likely reflects the more complex profile of the AOS plus aphasia cases in the current study. While durational stress contrast was sufficient to predict diagnostic group, error variability measures were significantly associated with AOS and can contribute to developing targeted intervention goals.     

Grammar and cognition: deficits comprehending counterfactuals in Turkish individuals with Broca’s aphasia

Background: Comprehending counterfactuals requires a well-developed cognitive system. Individuals with Broca’s aphasia have impaired cognitive functioning, which may affect their ability to comprehend counterfactuals.

Aims: This study investigated whether cognitive complexity involved in counterfactuals adds to sentence comprehension deficits in Broca’s aphasia.

Methods & Procedures: The sample consisted of 24 Turkish individuals with Broca’s aphasia (mean age: 52.7; SD: 12.7) who were matched in age with a control group of 15 neurologically intact Turkish individuals (mean age: 51.8; SD: 8.5). Each group completed a sentence comprehension task with three sentence conditions: nonconditional, factual, and counterfactual. Nonconditionals did not have if-embedding, whereas factual and counterfactual conditionals were morphosyntactically equivalent if-clauses, but only the latter was cognitively complex.

Outcomes & Results: Conditionals were more difficult to comprehend than nonconditionals for the Broca group. Counterfactuals were more difficult to comprehend than the morphosyntactically equivalent factual counterparts for the Broca group. There was no discrepancy between test conditions for the control group.

Conclusions: Individuals with Broca’s aphasia have difficulty processing counterfactuals due to morphosyntactic complexity (if-embedding) and the cognitive processes involved in comprehending counterfactuals. This indicates that cognitive complexity adds to sentence comprehension deficits in Broca’s aphasia.     

A pilot study exploring public awareness and knowledge of right hemisphere communication disorder compared with aphasia and stroke in Northwest London,UK

Background: No previously published research has investigated public awareness and knowledge of Right Hemisphere Communication Disorders (RHCD). In comparison, there are a handful of published studies that have investigated public awareness and knowledge of aphasia. The results of these studies indicate that awareness and knowledge is low but has marginally increased in recent years, due to international efforts to raise the public profile of the disorder.

Aims: The current study investigated public awareness and knowledge of RHCD and compared it to that of aphasia. Information regarding awareness and knowledge of stroke was also determined for those participants who did not have awareness of RHCD or aphasia.

Methods & Procedures: A face-to-face survey of 87 members of the public was undertaken in North West London, United Kingdom.

Outcomes and Results: Of the 87 survey respondents, only 9.2% reported having heard of RHCD and 4.6% met the criteria for having basic knowledge of this disorder. In comparison, 32.2% of participants had heard of aphasia and 24% had basic knowledge about it. While the results show that fewer people were aware and had knowledge of RHCD compared to aphasia, this difference was not significant. Of those participants who had heard of neither disorder, all had heard of and the majority had knowledge of stroke.

Conclusions: The findings suggested that awareness of RHCD amongst members of the public is low. It is suggested that in order to improve quality of services, funding and social re-integration following a right hemisphere stroke, raising public awareness and knowledge is necessary.     

Codeswitching and discourse markers in the narratives of a bilingual speaker with aphasia

Background: Codeswitching and discourse markers are proposed as potentially compensatory means to promote fluency in bilingual people diagnosed with nonfluent aphasia.

Aim: This paper examined four linguistic markers of aphasia and fluency—grammaticality, complexity, codeswitching, and discourse markers—in the narratives of a bilingual speaker, in order to assess whether and to what extent these phenomena are manifested in the two languages of a person with aphasia.

Methods & Procedures: Sixteen narratives per language were collected, using a cue word procedure, from a 59-year-old Yiddish–English bilingual with diagnosed moderate nonfluent aphasia. Analyses of frequency and locus of ungrammaticality, sentence complexity, codeswitching, and discourse markers were conducted as well as motivations for codeswitching.

Outcomes & Results: Findings showed more ungrammaticality in English (L2) than Yiddish (L1), relatively similar levels of complexity, and very similar use of discourse markers in both languages. Codeswitching was more prevalent in Yiddish (L1), motivated by lexical access difficulties, whereas in English (L2), codeswitching was motivated both by lexical access and cross-linguistic lexicalization differences.

Conclusions: Differential use of codeswitching across the languages of a bilingual person with nonfluent aphasia shows that different strategies are used to enhance fluency and compensate for ungrammaticality in each language. Clinically, the study shows the importance of assessment in both languages, and suggests that intervention in both languages should be considered pending further investigation.     

The comprehension of sentences with unaccusative verbs in aphasia: a test of the intervener hypothesis

Background: It is well accepted that individuals with agrammatic Broca’s aphasia have difficulty comprehending some sentences with filler-gap dependencies. While investigations of these difficulties have been conducted with several different sentence types (e.g., object relatives, Wh-questions), we explore sentences containing unaccusative verbs, which arguably have a single noun phrase (NP) that is base-generated in object position but then is displaced to surface subject position. Unaccusative verbs provide an ideal test case for a particular hypothesis about the comprehension disorder—the Intervener Hypothesis—that posits that the difficulty individuals with agrammatic Broca’s aphasia have comprehending sentences containing filler-gap dependencies results from similarity-based interference caused by the presence of an intervening NP between the two elements of a syntactic chain.

Aim: To assess a particular account of the comprehension deficit in agrammatic Broca’s aphasia—the Intervener Hypothesis.

Methods & Procedures: We used a sentence–picture matching task to determine if listeners with agrammatic Broca’s aphasia (LWBA) and age-matched neurologically unimpaired controls (AMC) have difficulty comprehending unaccusative verbs when placed in subject relative and complement phrase (CP) constructions.

Outcomes & Results: We found above-chance comprehension of both sentence constructions with the AMC participants. In contrast, we found above-chance comprehension of CP sentences containing unaccusative verbs but poor comprehension of subject relative sentences containing unaccusative verbs for the LWBA.

Conclusions: These results provide support for the Intervener Hypothesis, wherein the presence of an intervening NP between two elements of a filler-gap dependency adversely affects sentence comprehension.     

Developmental profile of speech-language and communicative functions in an individual with the Preserved Speech Variant of Rett syndrome

Objective: We assessed various aspects of speech-language and communicative functions of an individual with the preserved speech variant of Rett syndrome (RTT) to describe her developmental profile over a period of 11 years.

Methods: For this study, we incorporated the following data resources and methods to assess speech-language and communicative functions during pre-, peri- and post-regressional development: retrospective video analyses, medical history data, parental checklists and diaries, standardized tests on vocabulary and grammar, spontaneous speech samples and picture stories to elicit narrative competences.

Results: Despite achieving speech-language milestones, atypical behaviours were present at all times. We observed a unique developmental speech-language trajectory (including the RTT typical regression) affecting all linguistic and socio-communicative sub-domains in the receptive as well as the expressive modality.

Conclusion: Future research should take into consideration a potentially considerable discordance between formal and functional language use by interpreting communicative acts on a more cautionary note.     

Intensive multimodal communication treatment for people with chronic aphasia

Background: Clinicians often teach persons with aphasia (PWA) non-verbal strategies to compensate for reduced verbal communication. The manner in which they teach the strategies may have an impact on how well PWA generalise and use the strategies. Previously, multimodal communication treatment (MCT) taught multiple modalities simultaneously. While participants demonstrated some increase in the flexible use of strategies, many communication breakdowns continued to occur. Recent research suggests that intensive treatment protocols result in the greatest increase in skills.

Aims: The purpose of this study was to determine whether intensive (2–3 hours/day, 5 days/week, for 2 weeks) multimodality communication training for aphasia resulted in increased successful use of verbal and non-verbal communication modalities as well as increased successful communicative repairs during structured communication tasks.

Methods & Procedures: Three participants with chronic aphasia completed four baseline sessions, 10 treatment sessions across two phases (i.e., five sessions per phase), and three post-treatment sessions.

Outcomes & Results: Two of the three participants demonstrated gains in the acquisition of non-verbal strategies during training and increased use of strategies on a referential communication task.

Conclusions: Although MCT delivered intensely resulted in increased use of non-verbal modalities for two out of three participants, the results were similar to that achieved through the use of a non-intensive treatment protocol. Therefore, future research is needed to examine other potential modifications to maximise the gains people with aphasia receive from multimodal interventions.     

The role of intensity in constraint-induced language therapy for people with chronic aphasia

Background: Studies of intensive aphasia treatments vary widely in terms of treatment focus, in patient population and, in particular, in definition of what is considered “intensive”. Variability makes it difficult to compare among studies and to definitively determine whether more treatment is actually better. Constraint-induced language therapy (CILT) is one treatment that has been successfully replicated at approximately the same dosage with generally positive results.

Aims: The current study used a modified multiple baseline design across participants to investigate the administration of CILT at the standard intensive dosage of 30 hours over 2 weeks (CILT-I) compared to a more distributed dosage of 30 hours over 10 weeks (CILT-D).

Methods & Procedures: Eight participants with chronic aphasia participated in either CILT-I or CILT-D. Standardised and discourse measures were taken pre- and post-treatment and also 4 weeks after the completion of treatment. Discourse probes were administered after every 6 hours of treatment to assess change in productivity and efficiency over time.

Outcomes & Results: All of the participants who received CILT-I and CILT-D showed either an increased effect size on a discourse measure, a clinically significant change on a standardised battery or both. Gains were maintained in nearly all cases.

Conclusions: CILT administered in both intensive and distributed dosages resulted in positive changes in aphasia severity and discourse. This study adds evidence to the still inconclusive role of intensity to CILT.     

Semantic knowledge use in discourse produced by individuals with anomic aphasia

Background: Researchers have demonstrated that people with aphasia (PWA) have preserved semantic knowledge. However, some PWA have impaired access to certain types of knowledge more than others. Yet, all these studies used single concepts. It has not been demonstrated whether PWA have difficulty accessing certain types of features within a discourse sample.

Aims: The main goals of this study were to determine whether semantic knowledge and two category types were used differently within discourse produced by participants with anomic aphasia and healthy controls.

Methods & Procedures: Participants with anomic aphasia (n = 19) and healthy controls (n = 19) told stories that were transcribed and coded for 10 types of semantic knowledge and two category types, living and non-living things.

Outcomes & Results: A Poisson regression model was conducted. The results indicated a significant difference between the groups for the semantic knowledge types, sound and internal state, but no difference was found for category types. Yet the distribution of semantic knowledge and category types produced within the discourse samples were similar between the groups.

Conclusions: PWA might have differential access to certain types of semantic knowledge within discourse production, but it does not rise to the level of categorical deficits. These findings extend single-concept research into the realm of discourse.     

Rate of aphasia among stroke patients discharged from hospitals in the United States

Background: Estimated rates of post-stroke aphasia range from 18% to 38%. Despite the existence of several studies that have calculated rates of aphasia among stroke survivors, no specific study has emerged that describes the rate of post-stroke aphasia among stroke patients discharged from acute care hospitals in the United States (US).

Aim: To estimate the hospital discharge rate (HDR) of aphasia in stroke patients discharged from acute care hospitals in the US.

Methods & Procedures: Healthcare Cost and Utilization Project (HCUP) data (2011–2012) derived from a convenience sample of eight states (Oregon, Arizona, Colorado, Florida, Kentucky, North Carolina, South Carolina, Arkansas) were analyzed to calculate rate of aphasia.

Outcomes & Results: In 2011–2012, among 152,972 adults who were hospitalized for a stroke in the eight representative states, 28,086 (18.4%) were discharged with aphasia. The HDR of aphasia ranged from 14.3% to 24.9% across the eight states over the two-year period. The rate of aphasia was highest among Whites compared to Blacks, Hispanics and Other. Seventy-seven percent of the sample was age 65 and older, 56% was female and Medicare was the primary insurance type. Thirty-six percent of the sample had four or more comorbid conditions and more than half (52%) were discharged to skilled nursing, intermediate care or another type of facility.

Conclusions: The HDR of aphasia observed in this study is on the lower end of rates previously reported in other countries. The declining rate of stroke, the primary underlying cause of aphasia and the methodological approach used to calculate HDR of aphasia in this study, should be taken into consideration in the interpretation of these findings.     

Understanding the experience of driving with a passenger with aphasia

Background: Drivers and passengers often spend a great deal of time conversing when riding in a personal automobile. Under most circumstances, drivers are easily able to maintain a conversation with their passengers while safely operating their vehicle. However, this task may be challenging when the passenger riding in the car has aphasia since many people with aphasia supplement their limited verbal output with other communication modalities, such as writing, gesturing, and using body language.

Aims: The aim of this paper is to describe the experience of driving a personal automobile when a passenger with aphasia is riding in the car.

Methods & Procedures: A phenomenological approach was used to gain an understanding of the lived experience of driving a car with a passenger with aphasia. Nine people who regularly serve as the primary drivers of a person with aphasia were interviewed twice using a semi-structured interview guide. Data were analysed using thematic analysis.

Outcomes & Results: Three main themes characterised the drivers’ experiences of riding with an aphasic passenger: (1) communicating, (2) helping, and (3) adapting. The theme of communicating was specified in terms of time constraints, topic avoidance, and communication strategies. The theme of helping was constructed from two subthemes: avoiding accidents and navigating. Drivers reported that passengers needed to adapt to the car environment due to stroke-induced cognitive and physical deficits.

Conclusions: The findings describe various problems that people who drive an automobile with a passenger with aphasia experience and the ways in which they seek to overcome these problems. Clinicians should collaborate with drivers and passengers with aphasia to enhance the safety and quality of their in-vehicle experience.     

Implicit learning and implicit treatment outcomes in individuals with aphasia

Background: Implicit learning is a process of learning that occurs outside of conscious awareness and may be involved in implicit, exposure-based language training. However, research shows that implicit learning abilities are variable among individuals with aphasia, and it remains unknown whether individuals who show basic implicit learning abilities also benefit from implicit language training.

Aims: The aims of this series of experiments were to test implicit learning in individuals with agrammatic aphasia, examine the effects of a novel implicit language treatment, and investigate whether individuals with aphasia who show implicit learning ability also benefit from implicit treatment focused on passive sentence comprehension.

Methods & Procedures: Nine participants with chronic agrammatic aphasia and 21 neurologically intact participants completed a visuomotor serial reaction time test of implicit learning (Experiment 1). The participants with aphasia also completed a short-term novel implicit sentence comprehension treatment (Experiment 2) that consisted of five sessions of repeated exposure to grammatically correct passive sentences and matching photographs. Sentence comprehension was tested in multiple baseline sessions and on each day of training using a sentence–picture matching task. The relation between participants’ learning patterns across experiments was also examined.

Outcomes & Results: Individuals with agrammatic aphasia as well as neurologically intact adults demonstrated significant implicit sequence learning in the serial reaction time task. However, the participants with aphasia did not show concomitant improvement in sentence comprehension as a result of the implicit treatment protocol.

Conclusions: This study suggests that individuals with agrammatic aphasia demonstrate implicit learning ability; however, this ability does not necessarily promote successful outcomes in treatment that is based solely on implicit training methods.     

Cognitive-communication disorder following right hemisphere stroke: exploring rehabilitation access and outcomes.

Background: Rehabilitation positively influences return to activities and social roles in people with aphasia. The cognitive-communication disorder (CCD) found following a right hemisphere stroke has been less extensively researched with rehabilitation access and outcomes yet to be determined.

Objectives: To document rehabilitation access and outcomes for people with CCD post-stroke; and compare outcomes based on presence (viz CCD; aphasia) or absence of communication impairment.

Methods: A retrospective chart audit was completed for patients with first onset unilateral stroke, with a hospital length of stay (LOS) of at least two days and a communication assessment by a speech pathologist. Data extracted included presence and severity of communication impairment, access to and LOS in a rehabilitation unit, and functional outcome measures recorded at rehabilitation discharge.

Results: The majority of the 115 patients who met inclusion criteria were living independently (n = 112, 97.4%) at the time of stroke. CCD (66%) was diagnosed with similar frequency to aphasia (68%). The presence of communication impairment did not result in significant differences in rehabilitation LOS and discharge destination when compared to hemispheric strokes without communication impairment. Severity of CCD was an independent predictor of functional gain by rehabilitation discharge.

Conclusions: People with CCD require comparable access to rehabilitation as people with aphasia, and severity of CCD should be considered in determining rehabilitation LOS. A large number of people are discharged with ongoing CCD which warrants exploration of potential participation restrictions created by the communication impairment.     

Individual variability in attention and language performance in aphasia: a study using Conner’s Continuous Performance Test

Background: Individual variability in attention in aphasia is important because moment-to-moment fluctuations in attention could might influence language performance.

Aims: Moment-to-moment variability in performance has been considered a feature of aphasia. The aim of the current work is to study the possible relationship between moment-to-moment intraindividual fluctuations in attention and their possible relationship with language disorders in people with aphasia (PWA).

Methods & Procedures: 24 controls and 21 PWA matched by age and sex took part in the study. Language assessment included phonological processing (phonological discrimination, word and pseudoword repetition), lexical access (auditory lexical decision, spoken word-to-picture matching and naming), and semantic association (object–action association, semantic association, and odd-one-out). Attention assessment employed a comprehensive test of basic attention functions (Conner’s Continuous Performance Test II). We studied the association between indices of intraindividual variability in response time in Conner’s Continuous Performance Test and linguistic performance in both groups.

Outcomes & Results: PWA showed increased response times and also increased intraindividual variability in response speed. Moreover, only in this group, response speed variability was significantly associated with speech discrimination and with performance in semantic association tasks. Indices of intraindividual variability predicted performance in linguistic tasks in PWA, even after accounting for language performance in related tasks.

Conclusion: The current results provide additional support to evidence suggesting a relationship between attention skills and some aspects of linguistic performance in PWA, and draw attention to the putative importance of processing speed instability.     

Listener perceptions of simulated fluent speech in nonfluent aphasia

Background: People with aphasia (PWA) are frequently perceived less favourably by listeners than their peers. These perceptions include incorrect assumptions that can prevent successful social interactions. While communication partner training has been shown to improve social outcomes related to the listener, changing the verbal output of PWA may also yield more favourable listener perceptions about the speech, speaker, and their own affective response. We investigated the effects of artificially altered fluency (i.e., simulated fluency) on listeners’ subjective impressions.

Aims: The purpose of the study was to (1) confirm that listeners perceive PWA less favourably than their neurologically healthy peers and (2) determine the effects of simulated fluency on listener perceptions about PWA.

Methods & Procedures: Thirty-eight listeners heard nine narrative monologue language samples from three conditions (i.e., speakers with nonfluent aphasia, simulated fluent samples from the same speakers, and neurologically healthy speakers). Listeners responded to a nine-item questionnaire that probed perceptions about speech output, speaker attributes, and listener feelings.

Outcomes & Results: Listeners perceived PWA less favourably than their neurologically healthy peers. Simulated fluency yielded more positive listener perceptions for all questionnaire items except speech intelligibility, which was unchanged by simulated fluency.

Conclusions: Simulated fluency improved listener perceptions of PWA significantly, indicating that speech fluency may be a socially valid treatment target in aphasia. Beyond direct training of communication partners, changing the verbal output of aphasic speech can also yield more positive listener perceptions of PWA.     

Automatic feedback to promote safe walking and speech loudness control in persons with multiple disabilities: Two single-case studies

Objective: Assessing automatic feedback technologies to promote safe travel and speech loudness control in two men with multiple disabilities, respectively.

Method: The men were involved in two single-case studies. In Study I, the technology involved a microprocessor, two photocells, and a verbal feedback device. The man received verbal alerting/feedback when the photocells spotted an obstacle in front of him. In Study II, the technology involved a sound-detecting unit connected to a throat and an airborne microphone, and to a vibration device. Vibration occurred when the man's speech loudness exceeded a preset level.

Results: The man included in Study I succeeded in using the automatic feedback in substitution of caregivers’ alerting/feedback for safe travel. The man of Study II used the automatic feedback to successfully reduce his speech loudness.

Conclusion: Automatic feedback can be highly effective in helping persons with multiple disabilities improve their travel and speech performance.