Production and integrated training of adjectives in three individuals with nonfluent aphasia

Background: Current research in theoretical linguistics, experimental psychology, and clinical aphasiology suggests that adjective training may facilitate unique aspects of language production and functional communication in persons with aphasia. Although considerable research has been devoted to treatments targeting nouns and verbs, there has been relatively little treatment research directed towards adjectives.

Aims: The goal of this study was to further investigate the viability of adjective training in aphasia by applying an integrated treatment approach targeting adjective production in the context of single word, sentence, and discourse levels of communication. Specific objectives were to quantify baseline adjective production, acquisition of target structures, and treatment generalisation effects.

Method: A single-participant multiple-baseline design was used to evaluate treatment effects in three individuals with nonfluent chronic aphasia. A battery of experimental measures and standardised tests was also administered pre- and post-treatment to assess baseline performance and generalisation effects extending to adjectives, other parts of speech, sentence processing, and discourse production.

Outcomes & Results: Two of the three participants acquired the target structures and maintained criterion performance levels 1 month after treatment. In spite of differences in baseline performance and responsiveness to treatment, all three participants demonstrated significant gains on standardised measures of language production.

Conclusions: Findings add to existing literature supporting the viability of adjective training for individuals with aphasia. Participant characteristics and treatment factors that may contribute to variable outcomes are also discussed.     

Visual attention in a multiple‐choice task: Influences of image characteristics with and without presentation of a verbal stimulus

Background: Use of multiple‐choice items is common in the assessment of language comprehension. Stimulus‐driven aspects of multiple‐choice images may interfere with valid assessment. Understanding the influences of stimulus‐driven factors is crucial because individuals with neurological disorders have increased susceptibility to them.

Aims: The first goal of this study was to explore the influence of objectively measurable image characteristics in multiple‐choice image sets that are otherwise well controlled in terms of physical stimulus features on individuals' visual attention. The second goal was to explore viewers' visual attention under the influence of a verbal stimulus.

Methods & Procedures: The effects of controlled manipulation of physical image characteristics on visual attention in 40 healthy adults were assessed. Eye movements were recorded while participants viewed 40 image sets with and without a verbal stimulus. Within each set, two images shared the same image characteristics (colour, orientation, size, and luminance) and one image differed in terms of one of those characteristics.

Outcomes & Results: All characteristics had a significant influence on visual attention in verbal and nonverbal conditions. The influence of verbal stimuli on visual attention did not override the tendency for physical stimulus characteristics to distract attention from target images.

Conclusions: Research and clinical relevance is highlighted in terms of the potential for assessment confounds to be greater in individuals with neurological impairments.     

Overt use of a tactile/kinaesthetic strategy shifts to covert processing in rehabilitation of letter-by-letter reading

Background: Letter-by-letter readers identify each letter of the word they are reading serially in left to right order before recognising the word. When their letter naming is also impaired, letter-by-letter reading is inaccurate and can render even single word reading very poor. Tactile and/or kinaesthetic strategies have been reported to improve reading in these patients, but only under certain conditions or for a limited set of stimuli.

Aims: The primary aim of the current study was to determine whether a tactile/kinaesthetic treatment could significantly improve reading specifically under normal reading conditions, i.e., reading untrained words presented in free vision and read without overt use of the strategy.

Methods & Procedures: Three chronic letter-by-letter readers participated in a tactile/kinaesthetic treatment aimed at first improving letter-naming accuracy (phase 1) and then letter-by-letter reading speed (phase 2). In a multiple case series design, accuracy and speed of reading untrained words without overt use of the trained tactile/kinaesthetic strategy was assessed before phase 1, after phase 1, and again after phase 2.

Outcomes & Results: All three patients significantly improved both their speed and accuracy in reading untrained words without overt use of the trained tactile/kinaesthetic strategy. All three patients required the additional practice in phase 2 to achieve significant improvement. Treatment did not target sentence-level reading, yet two of the three patients became so adept that they could read entire sentences.

Conclusions: This study replicates previous findings on the efficacy of tactile/kinaesthetic treatment for letter-by-letter readers with poor letter naming. It further demonstrates that this treatment can alter cognitive processing such that words never specifically trained can be read in free vision without overtly using the trained strategy. The data suggest that an important element in achieving this level of generalisation is continuing training beyond the point of initial mastery (i.e., accurate letter naming).     

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.     

Challenges facing COS development for aphasia

ABSTRACT

Background: Difficulty in communicating (due to aphasia) can have serious consequences for patients in health care settings. Communication Partner Training is effective for improving communication between people with aphasia and health care professionals.

Aim and Objective: This study aims to evaluate the feasibility of developing and introducing a Communication Program which focuses on improving communication between nurses and persons with aphasia in a peripheral hospital setting.

Methods &; Procedures: A mixed-methods feasibility study was conducted with a pre-test post-test design in the quantitative part and two focus group discussions in the qualitative part. Nurses received training for communicating with persons with aphasia. In the pre-test and post-test, nurses filled in a questionnaire for barriers and facilitators and a feasibility questionnaire. Nurses’ attitudes towards the Communication Program were further explored in two focus group discussions.

Outcomes &; Results: Forty six nurses took part in the training sessions. Most nurses were satisfied about the Communication Program (24/30) and intended to continue using it (25/30). Almost all nurses saw positive effects for patients with aphasia (27/30), such as an increase in the ability to communicate. However, nurses reported that using the program was time consuming and that they still often experienced frustration when communicating with persons with aphasia.

Conclusions: Improving communication with persons with aphasia via the Communication Program seems feasible and valuable according to nurses. Nurses probably need more support during implementation of the Communication Program, mainly due to time barriers and the complexity of communicating with persons with aphasia. Further research should focus on revising the program, training health care professionals with different educational backgrounds, and assessing the implementation of this communication partner training in health care settings.     

Comparing monitoring and production based approaches to the treatment of phonological assembly difficulties in aphasia

Background: Waldron, Whitworth, and Howard (2011 Waldron, H., Whitworth, A. and Howard, D. 2011. Therapy for phonological assembly difficulties: A case series. Aphasiology, 25(4): 434–455. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]) replicated the auditory and monitoring therapy reported in a single case by Franklin, Buerk, and Howard (2002 Franklin, S., Buerk, F. and Howard, D. 2002. Generalised improvement in speech production for a subject with reproduction conduction aphasia. Aphasiology, 16(10/11): 1087–1114. [Taylor & Francis Online] , [Google Scholar]) with four participants with phonological assembly difficulties. No participant responded in the same way as Franklin et al.’s client MB and, notably, all improvements seen were item-specific, in contrast to MB who had shown generalised improvements in naming, repetition, and reading aloud. Waldron et al. attributed this difference to the combination of underlying impairments in their participants, in particular additional lexical deficits; it remains unknown whether Franklin et al.’s results would be replicated in someone with a more pure phonological assembly difficulty. It is also unknown whether a more direct therapy approach, targeting a reduction in the production of phonological errors, rather than improving monitoring, might also be effective with this client group.

Aims: The current study aimed to compare the effectiveness of the auditory and monitoring therapy reported by Franklin et al. (2002 Franklin, S., Buerk, F. and Howard, D. 2002. Generalised improvement in speech production for a subject with reproduction conduction aphasia. Aphasiology, 16(10/11): 1087–1114. [Taylor & Francis Online] , [Google Scholar]) with a production-focused therapy based on the articulatory kinematic treatment of apraxia of speech (AOS), in a single participant with phonological assembly difficulties.

Methods & Procedures: Participant RE received three consecutive therapy phases: Franklin et al.’s auditory therapy, followed by a new production therapy involving a hierarchy of articulatory kinematic cues and the production of minimal contrast pairs, and finally Franklin et al.’s monitoring therapy. As RE's linguistic profile was similar to that of Franklin et al.’s client, it was predicted that he would make similar gains, i.e., generalised improvement in the production of treated and untreated words, following all three therapy types.

Outcomes & Results: RE's naming of treated items improved significantly after both the production therapy and the monitoring therapy, but naming of untreated items did not improve and there were no naming improvements following the auditory therapy.

Conclusions: Two possible reasons why RE did not respond as predicted are discussed. First, that RE may have had additional lexical retrieval difficulties, in which case therapy could have improved the link between semantics and lexical phonology; and second, that RE may have had additional mild AOS, in which case therapy may have resulted in improved motor planning abilities. Neither of these hypotheses could fully account for all of RE's results. Nonetheless, the production therapy was shown to be an effective alternative approach for clients with phonological assembly difficulties, when a direct focus on speech production is needed.     

Language as a stressor in aphasia

Background: Persons with aphasia often report feeling anxious when using language while communicating. While many patients, caregivers, clinicians, and researchers would agree that language might be a stressor for persons with aphasia, systematic empirical studies of stress and/or anxiety in aphasia remain scarce.

Aim: The aim of this paper is to review the existing literature discussing language as a stressor in aphasia, identify key issues, highlight important gaps, and propose a programme for future study. In doing so we hope to underscore the importance of understanding aspects of the emotional aftermath of aphasia, which plays a critical role in the process of recovery and rehabilitation.

Main Contribution: Post stroke emotional changes in persons with chronic aphasia clearly has adverse effects for language performance and prospects of recovery. However, the specific role anxiety might play in aphasia has yet to be determined. As a starting point, we propose to view language in aphasia as a stressor, linked to an emotional state we term “linguistic anxiety”. Specifically, a person with linguistic anxiety is one in whom the deliberate, effortful production of language involves anticipation of an error, with the imminence of linguistic failure serving as the threat. Since anticipation is psychologically linked to anxiety and also plays an important role in the allostatic system, we suggest that examining physiologic stress responses in persons with aphasia when they are asked to perform a linguistic task would be a productive tool for assessing the potential relation of stress to “linguistic anxiety”.

Conclusions: Exploring the putative relationship between anxiety and language in aphasia, through the study of physiologic stress responses, could establish a platform for investigating language changes in the brain in other clinical populations, such as in individuals with Alzheimer's disease or persons with post-traumatic stress disorder, or even with healthy ageing persons, in whom “linguistic anxiety” might be at work when they have trouble finding words.     

Examining attention and cognitive processing in participants with self-reported mild anomia

Background: People who report mild anomia following stroke often score near or within normal limits on traditional assessments of language. Based on evidence of cognitive influences on linguistic production in people with aphasia, this study examined non-linguistic, cognitive function and its potential influence on word retrieval in individuals with mild anomia.

Aims: This study explored the following research questions: Do people with mild anomia have impaired performance on tasks which require (a) automatic vs controlled processing and/or (b) selective attention relative to neurologically typical controls?

Methods & Procedures: A total of 14 participants with mild anomia and 9 neurologically typical controls were tested using Covert Orienting of Visuospatial Attention Test (COVAT), alone and with linguistic interference, at two interstimulus intervals (ISI) representing automatic and controlled processing.

Outcomes & Results: Participants with anomia showed significantly slower responses on COVAT alone at 100 ms ISI (automatic processing) compared with controls. The groups did not differ significantly during COVAT alone at 800 ms ISI (controlled processing). Additionally, similar priming patterns were exhibited by both groups on COVAT alone during both interstimulus intervals, indicating an intact validity effect. However, participants with anomia demonstrated significantly delayed response times during the COVAT with linguistic interference, regardless of ISI.

Conclusions: Overall, participants with mild anomia demonstrated impairments most notably when interfering stimuli were present, indicating deficits in automatic processing and selective attention. Study results support clinical evaluation of non-linguistic cognitive abilities in individuals reporting anomia who score near or within normal limits on language assessments.     

Department of Veterans Affairs' contributions to treatment outcomes research in aphasia

Background: Since at least 1948, Veterans Administration (VA) clinicians have been reporting the outcomes of treatment administered to mend aphasia. These range from retrospective clinical observations to controlled, multicentre clinical trials. While the rigour of research varies among reports, the body of work is considerable.

Aims: The purpose of this paper is to review VA contributions to treatment outcomes research in aphasia.

Methods & Procedures: Examples of VA aphasia treatment outcomes research were selected from a corpus of over 100 reports. Each was classified in the traditional, five‐phase, treatment outcomes research model, and each was rated by a levels of evidence scale.

Outcomes & Results: VA aphasia treatment outcomes research, like the bulk of aphasia treatment outcomes research, is patchy. There is little evidence of systematic progression through the traditional, five‐phase, treatment outcomes research model. It is also difficult to classify and to assign a level of evidence to many investigations. There is no VA aphasia treatment outcomes research on the effectiveness of the few treatments that have been demonstrated to be efficacious. Nevertheless, the amount of VA aphasia treatment outcomes research is massive, and its contribution to what can be said about the influence of treatment on aphasia is considerable.

Conclusions: For almost 60 years the VA has been contributing to treatment outcomes research in aphasia. No other single healthcare system can match the volume of this research. Lack of a systematic research programme may limit precise conclusions, but it does not diminish the significant contributions.     

Returning to work with aphasia: A case study

Background: For some people with aphasia, returning to work will be their eventual goal. While there are reports in the literature of incidence of return to work, and general discussion of success, there are few documented in depth studies of what this might entail for the individual with aphasia.

Aims: This paper explores returning to work with aphasia, and examines the complex relationship between the person, the aphasia and the demands of employment.

Methods & Procedures: This is a detailed case report, describing and reflecting on the experiences of GD, who returned to work following his stroke and aphasia. Therapy focused specifically on work requirements is described and the factors affecting GD's return to work explored. An interview was used to elicit GD's reflections on his experiences.

Outcome & Results: GD's language skills improved over time and with therapy, and he developed several strategies that facilitated his communication. He was able to return to work (part-time) in a modified role and this was successful initially. After an extended period (～19 months) his employment was terminated and GD explored other options. He moved on to a volunteering and charity trustee role.

Conclusions: The success (or not) of returning to work with aphasia is multi-faceted and does not rest solely with the person with aphasia. The nature of the work may have a strong bearing on success, as will the ability and willingness of the employer to engage in the process. Partnership with the person and constant review of goals and management is of overwhelming importance. We need to consider what “success” may mean in this context and the need to consider therapeutic and rehabilitation needs over a longer time frame.