Stress and depression scales in aphasia: relation between the aphasia depression rating scale,stroke aphasia depression questionnaire-10, and the perceived stress scale

Background: Assessment and diagnosis of post-stroke depression (PSD) among patients with aphasia presents unique challenges. A gold standard assessment of PSD among this population has yet to be identified.

Objectives: The first aim was to investigate the association between two depression scales developed for assessing depressive symptoms among patients with aphasia. The second aim was to evaluate the relation between these scales and a measure of perceived stress.

Method: Twenty-five (16 male; 9 female) individuals with history of left hemisphere cerebrovascular accident (CVA) were assessed for depression and perceived stress using the Stroke Aphasic Depression Questionnaire-10 (SADQ-10), the Aphasia Depression Rating Scale (ADRS), and the Perceived Stress Scale (PSS).

Results: SADQ-10 and ADRS ratings were strongly correlated with each other (r = 0.708, p < 0.001). SADQ-10 ratings were strongly correlated with PSS ratings (r = 0.620, p = 0.003), while ADRS ratings were moderately correlated (r = 0.492, p = 0.027). Item analysis of each scale identified items which increased both inter-scale correlation and intra-scale consistency when excluded.

Conclusions: The SADQ-10 and ADRS appear to be acceptable measures of depressive symptoms in aphasia patients. Measurements of perceived stress may also be an important factor in assessment of depressive symptoms.     

The problems faced by informal carers to people with aphasia after stroke: A literature review

Background: In addition to other stroke related impairments, up to 12% of those who survive stroke have ongoing problems with aphasia. Research suggests that informal carers to those with aphasia after stroke experience a greater overall burden of care than those who care for stroke survivors without aphasia. One of the keys to understanding this is a clear appreciation of the problems faced by carers of stroke survivors with aphasia.

Aims: Via review of the literature to identify the problems faced by informal carers to those having aphasia after stroke.

Methods & procedures: Studies listed in AMED, CINAHL, EMBASE, MEDLINE, and PsycINFO databases were searched for articles published up until 10^th June 2012, using specified search terms. Reference lists of papers obtained were hand-searched. The studies were rated according to the appropriateness of the study design and the quality with which the research was executed. The results of studies of higher quality were given greater weighting.

Outcomes & Results: Fourteen studies were found that complied with the study criteria. The majority of research was cross-sectional. There was a balance of qualitative and quantitative studies. There were methodological problems with all of the studies. Seven studies were rated as low quality and the remainder were rated as moderate quality. It was established that there is reasonable evidence to suggest that informal carers to people with aphasia after stroke commonly experience problems in the following areas: role changes/new responsibilities, difficulties with social and leisure activities, communication difficulties with the stroke survivor, employment and financial problems, problems in dealing with health professionals, relationship difficulties with the stroke survivor, difficulties in family relationships, lack of support or respite, managing difficult behaviours in the stroke survivor, physical health problems/fatigue, and emotional health problems.

Conclusions: This paper provides an update and improvement upon a previous review of the literature in this subject area. There is a lack of longitudinal research and therefore little is known about how the problems experienced by informal carers of stroke survivors with aphasia change over time. Carer gender and carers’ perception of the self-care deficits of the stroke survivor emerge as potentially significant covariables requiring further investigation. Clinical implications of the findings and limitations are discussed.     

Severity of aphasia and recovery after treatment in patients with stroke

Background: Aphasia due to stroke is often very severe immediately after onset. However, knowledge about the impact of severity on therapeutic potential in the first months is scarce. The optimal therapeutic approach for patients with severe aphasia is still subject to debate.

Aims: To explore the recovery pattern of verbal communication in stroke patients with aphasia of varying degrees of severity receiving language therapy during the first 6 months poststroke.

Methods & Procedures: We used data from our previous trial in which 80 patients with aphasia due to stroke were randomised within the first 3 weeks postonset for either cognitive-linguistic therapy (CLT) or communicative therapy. All patients were tested at baseline and at 3 and 6 months postaphasia onset. We formed three severity groups, based on baseline Amsterdam–Nijmegen Everyday Language Test scores. We used repeated measures ANOVA to compare test scores at baseline and at 3 and 6 months poststroke onset for each of the three severity groups, stratified for the two treatments.

Outcomes & Results: Patients with severe or very severe aphasia improved substantially during follow-up, especially during the first 3 months poststroke. Improvement was less pronounced in the moderate to mild group. Although improvement did not differ significantly between the two treatment arms of the trial during the first 6 months poststroke, the very severe group seemed to benefit particularly from CLT (mean difference between treatments was 4.1 points; 95% CI: ?4.0 to 12.2).

Conclusions: Even in very severely aphasic patients, considerable improvement of functional communication is possible. These patients might benefit more from early initiated CLT therapy than generally assumed. Hence, speech and language therapists should not refrain from applying CLT in the acute phase of rehabilitation of severe aphasia.     

Subcortical aphasia: a specific clinical picture?

100 aphasic patients were examined with a scorable aphasia battery looking at the frequency of various aphasia types and the possible specificity of clinical pictures in deep-seated lesions. One month after onset, “atypical” aphasiological syndromes proved to be rare and to have the same frequency in patients with cortico-subcortical or capsulostriatal deep-seated lesions. In the latter condition, no specific clinical syndrome was brought out, although verbal comprehension disorders were usually less severe than in cortico-subcortical lesions.     

Cerebellar activity switches hemispheres with cerebral recovery in aphasia

The right postero-lateral cerebellum participates with the left frontal lobe in the selection and production of words. Using fMRI, we examined whether cerebellar activity switches hemispheres in parallel with recruitment of putative compensatory right homologous frontal regions in post-stroke aphasia. Re-examining the data of Blasi et al. [Blasi, V., Young, A. C., Tansy, A. P., Petersen, S. E., Snyder, A. Z., & Corbetta, M. (2002). Word retrieval learning modulates right frontal cortex in patients with left frontal damage. Neuron, 36(1), 159-170], we asked: (1) if activity in the right cerebellum was disrupted by a left frontal lesion, (2) if activity switched to the left cerebellum, and (3) if activity in the left cerebellum was modulated by learning, as was right frontal cortex. Fourteen age-matched controls and eight mildly aphasic stroke patients participated. Aphasic participants all had lesions due to unilateral left hemisphere stroke at or near Broca's area. Subjects silently performed a word stem completion task with either novel or repeated items. Activity in right cerebellum of aphasic individuals was minimal and was not modulated by learning, as for controls. However, we observed robust learning-related attenuation of the BOLD signal in the left postero-lateral cerebellum consistent with learning-related effects in right frontal cortex. These findings support the hypothesis that right frontal and left cerebellar circuits are likely to be functionally relevant to recovered/residual verbal function.     

Self-management of aphasia: a scoping review

Background: Self-management approaches are routinely used in chronic conditions to enable patients to take responsibility for their own care. A self-management approach may be appropriate for individuals with aphasia, but this has not been systematically investigated. The purpose of this review was to explore self-management in relation to aphasia.

Aims: The study aimed to explore existing research and intervention approaches for aphasia that incorporate self-management principles. A secondary aim was to examine the presence of the term self-management in the research literature and online resources relating to aphasia.

Methods & Procedures: A scoping review methodology was selected to explore literature relating to self-management of aphasia. Five databases were systematically searched in May 2017: PubMed, Embase, CINAHL, PsycINFO, and Linguistics & Language Behaviour Abstracts. Search terms used were aphasia OR dysphasia AND self-management OR self-directed OR self-care OR self-efficacy OR independence OR independent AND intervention OR treatment OR rehabilitation. A structured website search of aphasia, speech pathology and stroke associations from four English-speaking countries was performed in September 2017.

Outcomes & Results: A total of 43 studies met inclusion criteria for the literature review. Analysis of eligible studies showed three areas of aphasia intervention which incorporated principles self-management: 1) technology-based interventions, 2) group/community-based interventions, and 3) communication partner training. The structured website search revealed no information relating specifically to aphasia self-management.

Conclusions: Principles of self-management are being used in some aphasia interventions, but there is little evidence of a self-management approach being applied in aphasia. The term self-management is not widely present in aphasia literature and when it has been used tends to refer to self-administered treatment rather than a structured self-management approach.     

Functional connectivity between cortical hand motor and language areas during recovery from aphasia

Previous data indicate that in healthy subjects, there is a connectivity between cortical areas for hand movement and language on the left hemisphere. This link is possibly mediated by the so-called mirror neuron system. The present study investigated the functional relationship between linguistic and hand movement processing in patients who were recovering from post-stroke aphasia. The excitability of the right- and left-hand motor cortex during language production in patients who were recovering from post-stroke aphasia and age-matched controls was investigated. As control, phonation was investigated. Hand motor cortex excitability was assessed with Motor Evoked Potentials which were elicited by Transcranial Magnetic Stimulation (TMS). In patients, reading aloud enhanced the excitability of the right hemispheric hand motor cortex, whereas phonation had no effect on hand motor cortex excitability. In the control group, an increased excitability of the left hemispheric hand motor system was found during reading aloud in accordance with previous data. The present data suggest a functional connectivity between regions mediating hand movements and reading. This may indicate that the right hemisphere participates in language processing as far as involved in single word reading in patients recovering from aphasia. The coactivation between cerebral representations of hand movements and language may be used therapeutically for aphasia rehabilitation.     

Dynamic-intentional thalamic aphasia: a failure of lexical-semantic self-activation

Background: Previous research has described patients with aphasia from thalamic lesions, some of whom were non-fluent with intact comprehension, others who were fluent with impaired comprehension, and some of whom are non-fluent with impaired comprehension. Whereas these three subtypes usually have normal repetition, they had impaired naming, suggesting a deficit in lexical (phonological word forms)-semantic processing. We report a patient with a left thalamic hemorrhage in which lexical-semantic representations appear to be intact but the patient demonstrates an inability to spontaneously activate his lexical-semantic system Methods: A 82-year-old, right-handed man presented with decreased verbal fluency and memory loss following a thalamic hemorrhage. Neuropsychological assessment revealed significant decrements in verbal fluency with intact naming, comprehension, repetition and vocabulary. Conclusions: To the best of our knowledge this pattern of language disturbance, which mirrors dynamic aphasia induced by frontal lesions, has not previously been described with thalamic injury. The thalamus has strong connections with the frontal lobe and rather than degradation of lexical-semantic representations, this patient's thalamic lesion probably induced frontal lobe dysfunction with a failure to spontaneously active lexical semantic representations.     

Bedside screening for aphasia: a comparison of two methods

A prospective study was carried out in 50 consecutive patients referred with suspected aphasia in order to compare the Frenchay Aphasia Screening Test (FAST) with the Sheffield Screening Test for Acquired Language Disorders (SST). The study included 32 men and 18 women with a mean (SEM) age 53.9 (2) years. The comprehension scores on the FAST were correlated with receptive skills on the SSTr=0.74 (P<0.001). For expression, the correlation coefficient wasr=0.92 (P<0.001) and the total scores of the two tests correlated closelyr=0.89 (P<0.001). There was a positive correlation between total score on the FAST and the Short Orientation, Memory and Concentration test (SOMC)r=0.86 (P<0.001), and the total scores on the SST and SOMCr=0.91 (P<0.001). The Barthel index also correlated positively with the FASTr=0.59 (P<0.001) and SSTr=0.63 (P<0.001). The study demonstrated that the two tests are simple, short and similar in their predictive value for the screening and diagnosis of aphasia. The SST was found to have additional advantages, as it does not require any special equipment or stimulus cards, and it was not affected by visual neglect.     

Long-term recovery in stroke accompanied by aphasia: a reconsideration

Background: This work focuses on the 26 individuals who provided data to AphasiaBank on at least two occasions, with initial testing between 6 months and 5.8 years post onset of aphasia. The data are archival in nature and were collected from the extensive database of aphasic discourse in AphasiaBank.

Aims: The aim is to furnish data on the nature of long-term changes in both the impairment of aphasia as measured by the Western Aphasia Battery-Revised (WAB-R) and its expression in spoken discourse.

Methods & Procedures: AphasiaBank’s demographic database was searched to discover all individuals who were tested twice at an interval of at least a year with either (a) the AphasiaBank protocol or (b) the AphasiaBank protocol at first testing, and the Famous People Protocol (FPP) at second testing. The FPP is a measure developed to assess the communication strategies of individuals whose spoken language limitations preclude full participation in the AphasiaBank protocol. The 26 people with aphasia (PWA) who were identified had completed formal speech therapy before being seen for AphasiaBank. However, all were participants in aphasia centres where at least 3 hr of planned activities were available, in most cases, twice weekly. WAB-R Aphasia Quotient scores (AQ) were examined, and in those cases where AQ scores improved, changes were assessed on a number of measures from the AphasiaBank discourse protocol.

Outcomes & Results: Sixteen individuals demonstrated improved WAB-R AQ scores, defined as positive AQ change scores greater than the WAB-R AQ standard error of the mean (WAB-SEM); seven maintained their original WAB quotients, defined as AQ change scores that were not greater than the WAB-SEM; and the final three showed negative WAB-R change scores, defined as a negative WAB-R AQ change score greater than the WAB-SEM. Concurrent changes on several AphasiaBank tasks were also found, suggesting that the WAB-R improvements were noted in more natural discourse as well.

Conclusions: These data are surprising since conventional wisdom suggests that spontaneous improvement in language is unlikely to occur beyond 1 year. Long-term improvement or maintenance of early test scores, such as that shown here, has seldom been demonstrated in the absence of formal treatment. Speculations about why these PWA improved, maintained, or declined in their scores are considered.     

Measuring outcomes in aphasia research: A review of current practice and an agenda for standardisation

Background: Aphasia treatment research lacks a uniform approach to outcome measurement. A wide range of outcome instruments are used across trials and there is a lack of research evidence exploring the outcomes most important to stakeholders. This lack of standardisation produces research outcomes that are difficult to compare and combine, limiting the potential to strengthen treatment evidence through meta-analysis and data pooling. The current heterogeneity in aphasia treatment research outcome measurement may be addressed through the development of a core outcome set (COS)—an agreed standardised set of outcomes for use in treatment trials.

Aims: This article aims to provide a rationale and agenda for the development of a COS for aphasia treatment research.

Main Contribution: A review of the literature reveals heterogeneity in the way outcome measurement is performed in aphasia treatment research. COSs have been developed in a wide range of health fields to introduce standardisation to research outcome measurement. Potential benefits of COSs include easier comparison and combination of research outcomes, improved quality of systematic reviews and greater transparency in research reporting. The use of broad stakeholder consultation also supports the development of research outcomes that are meaningful. It is proposed that a COS for aphasia treatment research could be developed in three stages. First, consensus-based techniques would be used to reach international agreement on the outcomes that are most important to stakeholders. Second, a systematic review and meta-analysis of outcome instruments would provide synthesised evidence to support the choice of tools to most effectively capture the effects of aphasia treatments. Third, final agreement on a COS would be sought through an international consensus conference.

Conclusions: There is an identified need for standardisation in the way outcomes are selected and measured in aphasia treatment research. COS development may provide an effective, consensus-based solution to this need.     

Voice onset time in aphasia,apraxia of speech and dysarthria: a review

Voice onset time (VOT) is an objective temporal acoustic parameter defined as the time between the release of the oral constriction for plosive production and the onset of vocal fold vibrations. Many researchers consider VOT to be the most reliable acoustic cue for the distinction between voiced and voiceless stops. Previous studies have explored the physiological and linguistic factors underlying VOT production in normal speakers across several languages. A major clinical goal of acoustic analysis in speech disorder is to establish a correlation between the acoustic abnormalities and the phonetic perturbations. VOT could thus be used as an acoustic parameter that indicates the phonetic contrast between voiced and voiceless stops. This paper includes a critical review of the measurement of VOT, factors of VOT variability and the effect of neurogenic communication disorders on VOT. We review the VOT data from subjects who exhibit aphasia, apraxia of speech and dysarthria. These studies reveal that VOT perturbations in aphasia have been interpreted as phonemic or phonetic errors, while VOT abnormalities in apraxia of speech and dysarthria grossly reflect loss of motor control.     

BDNF genotype and tDCS interaction in aphasia treatment

Background

Several studies, including a randomized controlled trial by our group, support applying anodal tDCS (A-tDCS) to the left hemisphere during behavioral aphasia treatment to improve outcomes. A clear mechanism explaining A-tDCS's efficacy has not been established, but modulation of neuroplasticity may be involved.

Dissociation of severity of stroke and aphasia recovery early after intravenous recombinant tissue plasminogen activator thrombolysis

Clinical observation suggested to us that aphasia recovers relatively better than other deficits early after intravenous recombinant tissue plasminogen activator (IV-rtPA) treatment in stroke patients with minor deficits, while the reverse seemed the case in those with severe deficits. Retrospective analysis of acute ischemic stroke patients with aphasia admitted within 3 hours from symptom onset and treated with IV-rtPA was carried out. Stroke severity, aphasia and global neurological impairment were assessed at admission and 24 hours after thrombolysis. Improvement of aphasia (gain of ⩾1 point on the National Institutes of Health Stroke Scale [NIHSS] aphasia score) and global neurological improvement (gain of ⩾4 points on the NIHSS) were compared in minor strokes (NIHSS ⩽7), moderate strokes (NIHSS 8–15), and major strokes (NIH ⩾16). Sixty-nine of 243 stroke patients suffered from aphasia. Improvement of aphasia occurred in 7/16 minor strokes, 11/25 moderate strokes, and 7/28 severe strokes. Improvement of ⩾4 points on the NIHSS occurred in 3/16 minor strokes, 17/25 moderate strokes and 15/28 severe strokes. There is a significant (X² = 4.073, p < 0.05) dissociation of recovery of aphasia and that of other neurological deficits between minor versus severe strokes. This confirms the clinically suspected dissociation between a good early recovery from aphasia in minor strokes relative to recovery of other neurological deficits, as opposed to a better recovery from other neurological deficits than from aphasia in patients with severe strokes.     

Reading comprehension treatment in aphasia: a systematic review

Background: Reading difficulties often present as a consequence of aphasia. The specific nature of reading deficits varies widely in manifestation, and the cause of these deficits may be the result of a phonological, lexical semantic, or cognitive impairment. Several treatments have been developed to address a range of impairments underlying reading difficulty.

Aims: The purpose of this review is to describe the current research on reading comprehension treatments for persons with aphasia, assess the quality of the research, and summarize treatment outcomes.

Methods & Procedures: A systematic review of the literature was conducted based on a set of a priori questions, inclusion/exclusion criteria, and pre-determined search parameters. Results were summarized according to treatment type, methodologic rigor, and outcomes.

Outcomes & Results: Fifteen studies meeting criteria were identified. A variety of reading comprehension treatments was implemented including: oral reading, strategy-based, cognitive treatment, and hierarchical reading treatments. Quality ratings were highly variable, ranging from 3 to 9 (on a 12-point scale). Overall, 14 of the 18 individuals for whom individual data were provided demonstrated some degree of improvement (oral reading 4/5 participants, strategy based 4/6, and cognitive treatment 6/7). Gains were also evident for hierarchical reading treatment administered to participant groups via computer; however, the degree to which improvement reached statistical significance varied among studies.

Conclusions: Reading comprehension treatments have the potential to improve reading comprehension ability in persons with aphasia; however, outcomes were variable within and among treatment methods. We suggest focusing future research on factors such as participant candidacy and treatment intensity using increased methodological rigor.     

The incidence of cases of aphasia following first stroke referred to speech and language therapy services in Scotland

Background: Key to the provision of appropriate services is an understanding of the number of cases in a given population. This study examined the incidence of aphasia following first ever stroke. It was part of a larger study, the Aphasia in Scotland Study, which examined the provision of services for people with aphasia in Scotland.

Aims: The present study examines the incidence of aphasia referred to speech and language therapy services in people who have experienced their first ever stroke. The specific questions addressed were: What is the incidence of aphasia following first ever stroke? What is the percentage of aphasia following first ever stroke? What are the crude figures for aphasia following first ever stroke by age? What are the crude figures for aphasia following first ever stroke by gender? What are the crude figures for aphasia following first ever stroke by severity?

Methods & Procedures: All 14 health boards in Scotland were approached but only 3, NHS Borders, Orkney, and Shetland, were able to provide the level of information required. Respondents were asked to provide information about the age and gender and level of communication need of referred cases over a given year.

Outcomes & Results: Results suggested that the incidence of aphasia following first ever stroke was found to be 54, 57, and 77.5 per 100,000, for NHS Borders, Orkney, and Shetland respectively. This is slightly higher than in other comparable studies. The percentage of new cases of aphasia following a first ever stroke across NHS Borders, Orkney, and Shetland was 19, 22, and 34% respectively. The variability across the three sites is probably a function of the potential effect of small changes in the relatively low numbers. The majority of cases were, unsurprisingly, over 65 years of age but a substantial minority—17% (Shetland), 26% (Borders) and 36% (Orkney)—were below 65 years of age. One third of new cases resulted in severe aphasia. Although the proportions of men and women with aphasia were similar, women tended to be older at the point at which they experienced their first stroke.

Conclusions: The results are discussed in terms the practicalities of this sort of data collection exercise and the implications of the results for service delivery. There is a need for comparable local data collection exercises tied in to current epidemiological studies.     

Prognosis of aphasia in stroke patients early after iv thrombolysis

Objective

Stroke patients with aphasia have a high long-term morbidity. Intravenous rt-PA (iv) thrombolysis is given more deliberately to these patients. Early outcome data is lacking. Aim of this study was to determine early benefit from rt-PA in patients with aphasia.

Methods

Data of stroke patients treated by iv thrombolysis was scrutinized for the presence of aphasia defined as ≥1 point for aphasia on the National Institute of Health Stroke Scale (NIHSS). Improvement was defined as a gain of ≥1 point within 24 h. Cranial computed tomography (CT) scans were evaluated regarding early ischemic changes (EICs), infarct volume and localization.

Results

Fifty patients with aphasia were included. 16 (32%) of patients improved (4 (36%) minor, 7 (41%) moderate, 5 (23%) major stroke patients), while 44 (62%) remained unchanged. Of 28 patients with EICs, 10 (36%) improved compared to 7 out of 22 (32%) patients without (p = 0.773). Aphasia outcome was significantly associated with infarct volume at admission and at 24 h (Kruskal–Wallis, p = 0.033, p ≤ 0.001, respectively).

Conclusion

EICs are not predictive of aphasia outcome and patients with improvement showed smaller infarct volumes. One third improved within 24 h, while two thirds remained unchanged. This might justify a closer follow-up of aphasia in stroke patients at the acute stage.