Repetitive transcranial magnetic stimulation therapy for post-stroke non-fluent aphasia: A critical review

Objectives: To assess the efficacy of repetitive transcranial magnetic stimulation for post-stroke non-fluent aphasia through a review of current literature.

Methods: Three electronic databases (Medline, Embase & Scopus) were searched for articles. Relevant studies were further evaluated and studies that met inclusion criteria were reviewed.

Results: The literature search yielded 4713 studies. Thirty-five articles were further evaluated to be included. Thirteen met all inclusion criteria and were chosen for review. The studies provide moderate to strong evidence that rTMS may be an effective treatment for non-fluent stroke aphasia.

Conclusion: There are some strong studies evaluating the efficacy of rTMS in non-fluent stroke patients but further research is required to fully establish the usefulness of this treatment. Future directions and limitations are presented.     

The influence of race on SLP utilisation and costs among persons with aphasia

Background: Recent evidence suggests racial disparities exist in post-stroke conditions such as aphasia, yet the underlying cause of such disparities is unclear. Disparities in rehabilitation service utilisation have been previously proposed as a contributor to racial disparities in post-stroke outcomes.

Aim: To examine racial differences in speech–language pathology (SLP) service utilisation and costs among persons with aphasia being treated in acute care hospitals in North Carolina.

Methods & Procedures: The North Carolina Healthcare Cost and Utilization Project data from 2011 to 2012 were analysed to examine SLP service utilisation and costs for stroke patients with aphasia. Analyses included length of stay (LOS) and charges/costs of SLP services. Generalised linear models were constructed to determine the impact of demographic characteristics, stroke severity, residence, and hospital fixed effects (variability of hospital management practices) on SLP utilisation and costs.

Outcomes & Results: Approximately 5% more Blacks with aphasia were seen for SLP services than Whites with aphasia. LOSs were 2.1 days longer in acute care at 17% greater cost. Generalised linear models showed that Blacks with aphasia were seen for approximately 0.416 more visits than Whites after controlling for demographic characteristics, stroke/illness severity and residence and 0.25 more visits after controlling for hospital fixed effects. The slight increase in visits occurred at a cost of $57 when controlling for demographic characteristics, $63 when controlling for stroke/illness severity, $50 when controlling for residence, and $23 when controlling for hospital fixed effects.

Conclusions: Blacks with aphasia utilise more SLP services during longer LOSs and with greater costs when compared to Whites with aphasia.     

Fidelity to a motivational interviewing intervention for those with post-stroke aphasia: a small-scale feasibility study

Objective: Depression after stroke is common, and talk-based psychological therapies can be a useful intervention. While a third of stroke survivors will experience communication difficulties impeding participation in talk-based therapies, little guidance exists to guide delivery for those with aphasia. We need to understand how to adapt talk-based therapies in the presence of aphasia. This study aimed to explore the feasibility of motivational interviewing (MI) in people with post-stroke aphasia.

Methods: In a small-scale feasibility study, consecutive patients admitted to an acute stroke ward were screened for eligibility. People with moderate to severe aphasia were eligible. Those consenting received an intervention consisting of up to eight MI sessions delivered twice per week over four weeks. Sessions were modified using aids and adaptations for aphasia. Session quality was measured using the Motivational Interviewing Skills Code (MISC) to assess MI fidelity.

Results: Three consenting patients identified early post-stroke took part; one male and two females ages ranging between 40s and 80s. Participants attended between five and eight MI sessions over four weeks. Aids and adaptations included visual cues, rating scales, and modified reflections incorporating verbal and non-verbal behaviors. Sessions were tailored to individual participant need. Threshold MISC ratings could be achieved for all participants however, ratings were reduced when aids and adaptations were not used.

Discussion: This small-scale feasibility study suggests that it is feasible to adapt MI for people with moderate to severe post-stroke aphasia. These findings merit further exploration of adapted MI as an intervention for this patient group.     

“Do you have mowing the lawn?” – improvements in word retrieval and grammar following constraint-induced language therapy in primary progressive aphasia

Background: Much recent progress has been made in developing speech–language therapy in primary progressive aphasia (PPA). Several treatment approaches that have shown significant effects with people with aphasia have been adapted and re-evaluated for PPA. Constraint-induced aphasia therapy (CIAT) is a well-evaluated method that has yielded significant language improvements in people with post-stroke aphasia but has not yet been evaluated with people with PPA. Nevertheless, the combination of CIAT features like massed practice and a motivating communicative setting seem likely to make it a suitable tool for improving the speech and language performance of individuals with PPA as well.

Aims: This study investigates the effectiveness of a modified CIAT protocol on word retrieval, grammatical structure and connected speech in two individuals with non-fluent variant PPA (nfvPPA).

Methods and procedures: Two participants with nfvPPA took part in a 9-day intensive CIAT-based group therapy with additional computer-based home training. Stimuli were 120 photos of people performing daily life activities, which could be described using a simple (e.g., “The man is mowing the lawn”) or reduced (e.g., “mowing the lawn”) sentence structure. During the treatment phase, the participants were required to request picture cards from other group members using spoken language only. The task difficulty was increased hierarchically (shaped) in accordance to each participant’s performance level.

Outcomes and results: Directly after therapy, both participants achieved significant improvements in their noun and verb naming accuracy and their grammatical structure for trained items. Training effects were maintained 2 months after therapy. Moreover, generalisation to different pictures of the same item was found for both participants and one participant also showed improved grammatical structure when describing untrained pictures. No significant generalisation to untrained connected speech samples was observed for either participant.

Conclusion: This study illustrates that CIAT can be effective in people with PPA. However, further modifications of CIAT should be considered to facilitate generalisation and in order to determine which aspects of the treatment are most important.     

Combating social isolation for people with severe chronic aphasia through community aphasia groups: consumer views on getting it right and wrong

Background: Group participation has been demonstrated to have a range of benefits for people with chronic aphasia yet the strength of empirical findings is limited by the under-representation of people with severe aphasia. Little is known about what people with severe aphasia want, need and receive through participation in aphasia groups. Understanding the barriers and facilitators experienced by this population may assist the development of long-term strategies to manage significant communication disability.

Aims: This study explored community aphasia group participation from the perspectives of people with severe aphasia.

Method & Procedures: An interpretative phenomenological approach was employed to examine the reflections and experiences of seven people with severe, chronic aphasia. Reflections stemmed from people with aphasia who had withdrawn from groups as well as people who remained. Semi-structured interviews were conducted using techniques for enabling the participants to participate as fully as possible in the interviews. Field notes and journal entries also constituted data. Thematic analysis was used with all data sources.

Outcomes & Results: Analysis revealed three core themes associated with community aphasia group participation experiences. Participants with severe aphasia can initially perceive the community aphasia group to be high risk. As a consequence, the group participation proposition can be met with substantial apprehension. Compared to participants with mild and moderate aphasia, the participants with severe aphasia demonstrated a need for increased structure and use of physical materials to support them to successfully interact and integrate in the group. Despite the need for increased structure, participants with severe aphasia valued group environments that offered authentic interaction opportunities and that provided a platform for them to demonstrate and reveal their individual strengths, most notably as active listeners.

Conclusions: Participation in community aphasia groups presents additional challenges for people with severe aphasia. They risk becoming overwhelmed and excluded if the group is not adequately structured and resourced to support their interaction. People with severe aphasia value the explicit use of physical materials and group activities that support them to engage in group-based interactions. People with severe aphasia also seek to participate in authentic and meaningful activity that enables them to demonstrate identity and competency. In a community aphasia group that has a supportive communication environment, people with severe aphasia can experience fulfilling interactions and view themselves as valued group contributors.     

A comparison of two working memory tasks in aphasia

Background: Overall, there is growing consensus that working memory (WM) should be routinely assessed in individuals with aphasia as it can contribute significantly to their level of language impairment and be an important factor in treatment planning. However, there is still no consensus in the field as to which tasks should be used to assess WM in aphasia. The two main alternatives are adapted complex span tasks and N-back tasks. Both have been used interchangeably in previous studies of WM in aphasia, even though the correspondence between the two tasks has not been properly established.

Aims: The current study investigates the relationship between two WM tasks—complex span and N-back tasks—in a large sample of individuals with aphasia. The relationships of these tasks to measures of language comprehension are also explored, as well as differences in performance patterns between individuals with non-fluent and fluent aphasia.

Methods & Resources: Forty-four participants with aphasia (non-fluent: n = 27; fluent: n = 13; mixed: n = 4) were examined with a modified listening span task (Ivanova & Hallowell, 2014), an auditory verbal 2-back task, and a standardised Russian language comprehension test.

Outcomes & Results: Results revealed a moderate relationship between the two WM measures, but demonstrated a divergence in terms of their relationship to language comprehension. Performance on the modified listening span task was related to language comprehension abilities, but performance on the 2-back task was not, suggesting that the two tasks primarily index different underlying cognitive mechanisms. Furthermore, the relationship between the modified listening span task and language comprehension was significant for individuals with non-fluent aphasia, but not for those with fluent aphasia.

Conclusions: Overall, the data demonstrate that while performance of individuals with aphasia was related on the two tasks, the two tasks cannot be substituted for one another without further inquiries into their underlying differences.     

Effects of high-frequency repetitive transcranial magnetic stimulation on reducing hemiplegic shoulder pain in patients with chronic stoke: a randomized controlled trial

Objective: To examine whether high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS), applied over the primary motor cortex of the affected hemisphere, could be used to manage hemiplegic shoulder pain (HSP).

Methods: Twenty-four chronic stroke patients with chronic HSP, randomly assigned into the rTMS group (10 sessions of high-frequency stimulation) or the sham group (sham stimulation), were performed. The Numeric Rating Scale (NRS) was used to evaluate the intensity of pain at pretreatment, and at 1 day, and 1, 2 and 4 weeks after treatment. Changes in upper-limb motor function were evaluated using the Motricity Index (MI-UL) and modified Brunnstrom Classification (MBC).

Results: When compared to pretreatment, the rTMS group showed a significant decrease in the NRS score at 1 day, and 1, 2 and 4 weeks after finishing rTMS sessions, with no significant change in the sham group. The NRS score after the rTMS sessions reduced by 30.1% at 1 day, 29.3% at 1 week, 28.0% at 2 weeks and 25.3% at 4 weeks. Passive shoulder range of motion, MI-UL, and MBC, however, did not significantly change in either group.

Conclusions: High-frequency rTMS could be used as a safe, beneficial therapeutic tool to manage HSP. We think it can be used as an adjuvant therapeutic modality to enhance the therapeutic outcome of HSP.     

Recognition of thematic and taxonomic conceptual relations in patients with aphasia

Background: There is mounting evidence that there exist conceptual non-verbal deficits in patients with aphasia. In the current paper, taxonomic and thematic conceptual relations are the focus of interest. There is a debate surrounding this topic regarding whether they are part of the same semantic system or there are independent systems dedicated to each kind of relations.

Aims: Our aim was to study and look for possible dissociations in a group of fluent and non-fluent aphasic patients on their ability to recognise conceptual relations (taxonomic and thematic).

Methods & Procedures: Previous studies have usually proposed forced-choice tasks, which give the patients closed response options and do not allow the researcher to assess the criteria for the choice the participants have made. In the following study we assigned different types of conceptual tasks (forced choice and free choice) to a group of 25 stroke patients (7 fluent and 18 non-fluent aphasic patients), as well as 30 healthy control participants. We assessed the hit rates and the response criteria followed by the patients.

Outcomes & Results: The results showed that although all aphasic patients experienced difficulties in establishing both types of conceptual relations in verbal tasks, dissociations were observed particularly in non-verbal tasks showing poor performance in thematic relations. This was especially noticeable in non-fluent aphasic patients. Meanwhile, fluent aphasic patients showed more difficulty in establishing taxonomic relations in the pictorial free-choice task and a tendency to use thematic criteria.

Conclusion: These results support the claim that there exist separate systems for both kinds of conceptual relations. Implications for the assessment of semantic deficits in aphasic patients were discussed.     

Clinicians’ perceptions of delivering new models of high intensity aphasia treatment

Background: While evidence suggests that intensive aphasia therapy is associated with positive patient outcomes, speech language pathologists continue to report delivering therapy at low intensity schedules. Investigation of the barriers and enablers of delivering intensive therapy in hospital settings is needed to help address this evidence–practice gap.

Aims: To explore clinicians’ perceptions of delivering high intensity aphasia treatment through three different service models and their recommendations for future directions in implementing high intensity aphasia clinics in a public health setting.

Methods & Procedures: A sequential mixed methods design was employed. Thirteen speech language pathologists who provided intensive aphasia therapy to 31 patients across three facilities as part of a larger study consented to participate. Participants contributed to a log of barriers and facilitators while delivering treatment and completed a questionnaire in the last week of treatment. Findings were used to inform the question guide for a focus group interview conducted with nine of the clinicians post-treatment.

Outcomes & Results: Most clinicians found the increased intensity of treatment more difficult to deliver than standard treatment, and reported barriers included patient fatigue, patient personal factors, locating resources, scheduling and coordination issues, and clinician workload and potential burn-out. Emotional challenges were less expected and were potentially intensified by the frequency of contact with patients. Despite this, clinicians remained dedicated, and were motivated by patient progress, peer support and the opportunity to prove the worth of speech language pathology. They were positive about the perceived benefits of patient confidence, clinician development, teamwork, and the relationships that formed between patients, carers and clinicians.

Conclusions: Clinicians agreed that delivering the treatment brought great rewards and benefits, but also challenges. Communicating the benefits and finding ways to address the barriers identified by the participants of this study may be instrumental in assisting future implementation of high intensity models of aphasia treatment in existing services.     

Communication and quality of life outcomes from an interprofessional intensive,comprehensive, aphasia program (ICAP)

Background: Intensive Comprehensive Aphasia Programs (ICAPs) have developed in response to a growing need for treatments which produce changes in language function in people with aphasia, especially in the chronic phase of recovery. ICAPs are growing in number and several papers have presented preliminary results of their use, but little data exist about their efficacy or effectiveness.

Objective: This paper explores the communication effects of an ICAP program that incorporated evidenced-based individual and group treatment in an interprofessional program.

Method: Twenty-seven individuals with chronic aphasia were provided with 30 h of interprofessional treatment a week for a four-week period in both individual and group formats. A delayed treatment, within-participant research protocol was used. Language measures were taken at two intervals pre- and two intervals post treatment. Functional, narrative, and quality of life measures were taken once pre and once post treatment.

Results: Significant change was observed on targeted language functions post treatment. Significant treatment effects were also observed on functional and quality of life measures as well as on all impairment-based language measures for the group.

Conclusion: The results provide evidence of linguistic and quality of life change in individuals with chronic aphasia who were treated in an interprofessional ICAP.     

The feasibility of an acute high-intensity exercise bout to promote locomotor learning after stroke

Background: People post-stroke can learn a novel locomotor task but require more practice to do so. Implementing an approach that can enhance locomotor learning may therefore improve post-stroke locomotor recovery. In healthy adults, an acute high-intensity exercise bout before or after a motor task may improve motor learning and has thus been suggested as a method that could be used to improve motor learning in neurorehabilitation. However, it is unclear whether an acute high-intensity exercise bout, which stroke survivors can feasibly complete in neurorehabilitation session, would generate comparable results.

Objective: To determine a feasible, high-intensity exercise protocol that could be incorporated into a post-stroke neurorehabilitation session and would result in significant exercise-induced responses.

Methods: Thirty-seven chronic stroke survivors participated. We allocated subjects to either a control (CON) or one of the exercise groups: treadmill walking (TMW), and total body exercise (TBE). The main exercise-induced measures were: average intensity (% max intensity) and time spent (absolute: seconds; normalized: % total time) at target exercise intensity, and magnitudes of change in serum lactate (mmol/l) and brain-derived neurotrophic factor (BDNF; ng/ml).

Results: Compared to CON, both exercise groups reached and exercised longer at their target intensities and had greater responses in lactate. However, the TBE group exercised longer at target intensity and with greater lactate response than the TMW group. There were no significant BDNF responses among groups.

Conclusions: An acute high-intensity exercise bout that could be incorporated into a neurorehabilitation learning-specific session and results in substantial exercise-induced responses is feasible post-stroke.     

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.     

Cross-linguistic transfer effects of verb-production therapy in two cases of multilingual aphasia

Background: Verb retrieval is challenging for monolingual and multilingual speakers with aphasia. Previous research on bilingual aphasia shows equivocal results of cross-linguistic transfer and inhibition.

Aims: This study explores the impact of verb-production treatment in the treated and untreated languages of two bilingual speakers with aphasia. The main goals were to explore treatment effects, possible cross-linguistic transfer effects and to investigate possible inhibition of the untreated languages.

Methods & Procedures: The participants were one trilingual speaker (Portuguese-Ronga-Norwegian) with nonfluent aphasia and one bilingual speaker (English-Norwegian) with fluent aphasia. They received two types of treatment: communication-based therapy and Semantic Feature Analysis. Treatment was conducted in Norwegian, a late-acquired language for both speakers. Treatment effects were measured in action naming tasks and narrative tasks in the treated language as well as the untreated languages.

Outcomes & Results: Overall, the participants responded positively to the verb production treatments. This was demonstrated at the lexical level and also in discourse production, especially in the treated, but also in the untreated languages. No inhibition of the untreated languages was found.

Conclusions: The data provide evidence for positive effects of verb-retrieval treatment provided in sentence contexts in a late-learned weaker language of multilingual speakers with aphasia. The treatments did not lead to an unwanted inhibition of the untreated language, which is an important finding for clinicians as well as for researchers. The results provide evidence for a shared conceptual network of the languages in bilingual speakers, supporting current models of bilingual language processing.     

Telerehabilitation of anomia in primary progressive aphasia

Background: The efficacy of telerehabilitation-based treatment for anomia has been demonstrated in post-stroke aphasia, but the efficacy of this method of anomia treatment delivery has not been established within the context of degenerative illness.

Aims: The current study evaluated the feasibility and efficacy of a telerehabilitation-based approach to anomia treatment within the three subtypes of primary progressive aphasia (PPA).

Methods & Procedures: Each of the three telerehabilitation participants represented a distinct subtype of PPA. Following a baseline evaluation of language and cognition, a phonological treatment and an orthographic treatment were administered to all participants over the course of 6 months. One month after the end of treatment, a post-treatment evaluation began. All treatment sessions and the majority of the evaluation sessions were administered via telerehabilitation. Treatment effects were examined within each subject, and treatment effects were also compared between each telerehabilitation participant and a group of in-person participants who had the same subtype of PPA.

Outcomes & Results: All three telerehabilitation participants exhibited positive treatment effects. CGR (nonfluent/agrammatic variant PPA) and WCH (logopenic variant PPA) showed maintenance of naming for prophylaxis items under both treatment conditions, while ACR (semantic variant PPA) demonstrated increased naming of remediation items under the phonological treatment condition. Compared to in-person participants with the same subtype of PPA, each of the telerehabilitation participants typically showed effects that were either within the expected range or larger than expected.

Conclusions: Telerehabilitation-based anomia treatment is feasible and effective in all three subtypes of PPA.     

People with aphasia’s perception of the therapeutic alliance in aphasia rehabilitation post stroke: a thematic analysis

Background: The therapeutic alliance has been found to be a critical component of treatment delivery in mental health interventions. This construct may have the potential to inform both treatment efficacy and adherence in aphasia rehabilitation. However, little is known about how people with aphasia perceive therapeutic alliance construction in the context of aphasia rehabilitation.

Aims: This study aimed to investigate people with aphasias’ subjective experiences and reflections of constructing and maintaining therapeutic alliances in aphasia rehabilitation.

Methods & procedures: In-depth interviews were conducted with eighteen people with aphasia who had received aphasia rehabilitation following a stroke. Interviews were subject to thematic analysis.

Outcomes & results: Data analysis revealed five core themes: (1) readiness to contribute to the alliance; (2) proximity with the therapist; (3) perceived attunement with the therapist; (4) receiving information; and (5) collaborative engagement. The therapist’s perceived ability to read and respond effectively to individuals’ relational and situational needs contributed to the success of the alliance.

Conclusions: These findings offer novel insights into current practice, highlighting considerable variation in alliance formation across the profession, with ineffectual alliances obstructing engagement and eroding hope and effective alliances promoting adherence and instilling hope. Further research is recommended to understand which aspects of the therapeutic alliance are essential for optimising therapeutic efficacy.     

‘It will get even better’: preliminary findings from a trauma-focused psychotherapy effectiveness study reveal false positive patients’ long-term outcome expectations after the treatment

Background: There is considerable evidence that outcome expectations may predict psychotherapy outcomes. However, little is known about the long-term outcome expectations following the end of the treatment.

Aims: The aim of this study was to evaluate patients’ long-term outcome expectations after trauma-focused post-traumatic stress disorder (PTSD) psychotherapy in a single group effectiveness study.

Methods: Twenty participants with various traumatic experiences who completed the Brief Eclectic Psychotherapy for Post-Traumatic Stress Disorder (BEPP) and all the assessments were included into the study. Self-report measures were used to evaluate the therapeutic outcomes: Impact of Event Scale–Revised (IES-R), Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) at pre-treatment, post-treatment, and 6-month follow-up. Subjective Units of Distress Scale was used to measure long-term outcome expectations at post-treatment, asking participants to measure the expected distress in 6 months following the treatment. Assessments at 6-month follow-up were used to estimate the accuracy of patients’ expectations of their distress at previous post-treatment assessment.

Results: Significant decline of PTSD symptoms at post-treatment with large effect sizes was observed. At post-treatment assessment participants expected significant improvement of their condition in 6 months after the treatment. However, therapeutic effects remained stable at the 6-month follow-up.

Conclusion: It is concluded that the PTSD patients, even after successful trauma-focused treatment, tend to expect further significant positive changes. However, therapeutic effects were stable half a year after the psychotherapy, and patients tend to have false expectations about further improvement of their condition.