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International Journal of Stroke :... Dec 2021This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing... (Review)
Review
This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing on: (1) when and for whom language therapy is most effective, (2) the variety of approaches that can be effective for different individuals, and (3) the extent to which behavioral therapy might be augmented by non-invasive brain stimulation and/or medications.
Topics: Aphasia; Humans; Language Therapy; Neurologists; Speech Therapy; Stroke; Stroke Rehabilitation
PubMed: 33949274
DOI: 10.1177/17474930211017807 -
Continuum (Minneapolis, Minn.) Feb 2019This article reviews two of the primary progressive aphasias (PPAs), disorders characterized by the early and predominant impairment of language, and primary progressive... (Review)
Review
PURPOSE OF REVIEW
This article reviews two of the primary progressive aphasias (PPAs), disorders characterized by the early and predominant impairment of language, and primary progressive apraxia of speech, a degenerative motor speech disorder that is closely related to PPA. An outline of the history and controversy surrounding how these disorders are classified is provided before the article focuses on each disorder's clinical and imaging features.
RECENT FINDINGS
Over the past decade, the classification of degenerative speech and language disorders has been refined. Clinical, imaging, and pathologic evidence suggests that primary progressive apraxia of speech is a distinct degenerative disorder. Furthermore, multiple lines of evidence have highlighted issues with nonfluent/agrammatic variant PPA, which complicates the diagnosis, prognosis, and study of this disorder. Semantic variant PPA, while not without controversy, remains one of the most well-defined disorders, with good clinicopathologic correlation.
SUMMARY
Accurate classification and diagnosis of these degenerative speech and language disorders is crucial in clinical practice and ongoing research efforts. For nonfluent/agrammatic variant PPA, the authors suggest emphasizing agrammatism as the core inclusion criterion and taking care not to include patients with isolated or predominant apraxia of speech. Isolated apraxia of speech can be the manifestation of a degenerative disease and, based on the different prognosis, should be recognized as distinct from PPA. Finally, it is important to recognize that some patients with semantic dementia, despite sharing the same pathologic associations, may not meet criteria for PPA.
Topics: Aged; Aphasia, Primary Progressive; Apraxias; Brain; Female; Fluorodeoxyglucose F18; Frontotemporal Dementia; Humans; Magnetic Resonance Imaging; Neurologic Examination; Neuropsychological Tests; Positron-Emission Tomography; Speech
PubMed: 30707189
DOI: 10.1212/CON.0000000000000699 -
JAMA Neurology Dec 2018Aphasia is a debilitating language disorder for which behavioral speech therapy is the most efficient treatment, but therapy outcomes are variable and full recovery is... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Aphasia is a debilitating language disorder for which behavioral speech therapy is the most efficient treatment, but therapy outcomes are variable and full recovery is not always achieved. It remains unclear if adjunctive brain stimulation (anodal transcranial direct current stimulation [A-tDCS]) applied during aphasia therapy can improve outcomes.
OBJECTIVE
To examine the futility of studying A-tDCS as an adjunctive intervention during speech therapy to improve speech production (naming) for individuals with long-term poststroke aphasia.
DESIGN, SETTING, AND PARTICIPANTS
Double-blinded, prospective randomized clinical trial using a futility design to test adjunctive A-tDCS during speech therapy. The setting was an outpatient clinic. Enrollment of individuals began in August 2012 and was completed in March 2017, and the duration of follow-up was 6 months. Analyses began in April 2017. The study recruited from a volunteer sample, and 89 patients were screened. Patients with long-term (>6 months) aphasia due to 1 previous left hemisphere stroke were enrolled. In comparing A-tDCS and sham tDCS, patients were matched based on site (University of South Carolina or Medical University of South Carolina), baseline age, type of aphasia, and aphasia severity.
INTERVENTIONS
Outpatient speech therapy for 3 weeks (15 sessions, 45 minutes each) combined with either A-tDCS vs sham tDCS applied to preserved left temporal lobe regions.
MAIN OUTCOMES AND MEASURES
The primary outcome was the ability to name common objects, assessed twice before and after therapy.
RESULTS
A total of 74 patients were enrolled. Participants had a mean (SD) age of 60 (10) years, had 15 (2) years of education, and were 44 (40) months from stroke onset. There were 52 men (70%) and 62 non-Hispanic white individuals (84%). Most were retired or not employed (59 [80%]). Broca aphasia was the most common aphasia type (39 [52.7%]). The adjusted mean (SE) change from pretreatment baseline in correct naming was 13.9 (2.4) words (95% CI, 9.0-18.7) for A-tDCS and 8.2 (2.2) words (95% CI, 3.8-12.6) for sham tDCS, with mean (SE) A-tDCS difference of 5.7 (3.3) words (95% CI, -0.9 to 12.3), indicating a relative 70% increase in correct naming for A-tDCS relative to sham. The futility hypothesis P value was .90, indicating failure to reject the null hypothesis and, therefore, providing no evidence that further study of A-tDCS is futile. No serious adverse events were associated with A-tDCS.
CONCLUSIONS AND RELEVANCE
Our findings provide motivation to proceed with another trial to study the effect of A-tDCS on the outcome of aphasia treatment in individuals poststroke. Anodal tDCS during speech therapy is feasible and potentially transformative for aphasia treatment and should be further studied.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01686373.
Topics: Aged; Aphasia; Aphasia, Broca; Combined Modality Therapy; Double-Blind Method; Female; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Placebos; Research Design; Speech Therapy; Stroke; Temporal Lobe; Transcranial Direct Current Stimulation
PubMed: 30128538
DOI: 10.1001/jamaneurol.2018.2287 -
Journal of Speech, Language, and... Nov 2019Purpose Recovery from aphasia is thought to depend on neural plasticity, that is, functional reorganization of surviving brain regions such that they take on new or... (Review)
Review
Purpose Recovery from aphasia is thought to depend on neural plasticity, that is, functional reorganization of surviving brain regions such that they take on new or expanded roles in language processing. To make progress in characterizing the nature of this process, we need feasible, reliable, and valid methods for identifying language regions of the brain in individuals with aphasia. This article reviews 3 recent studies from our lab in which we have developed and validated several novel functional magnetic resonance imaging paradigms for language mapping in aphasia. Method In the 1st study, we investigated the reliability and validity of 4 language mapping paradigms in neurologically normal older adults. In the 2nd study, we developed a novel adaptive semantic matching paradigm and assessed its feasibility, reliability, and validity in individuals with and without aphasia. In the 3rd study, we developed and evaluated 2 additional adaptive paradigms-rhyme judgment and syllable counting-for mapping phonological encoding regions. Results We found that the adaptive semantic matching paradigm could be performed by most individuals with aphasia and yielded reliable and valid maps of core perisylvian language regions in each individual participant. The psychometric properties of this paradigm were superior to those of other commonly used paradigms such as narrative comprehension and picture naming. The adaptive rhyme judgment paradigm was capable of identifying fronto-parietal phonological encoding regions in individual participants. Conclusion Adaptive language mapping paradigms offer a promising approach for future research on the neural basis of recovery from aphasia. Presentation Video https://doi.org/10.23641/asha.10257584.
Topics: Aphasia; Brain Mapping; Forecasting; Humans; Language; Magnetic Resonance Imaging; Phonetics; Reproducibility of Results; Semantics
PubMed: 31756153
DOI: 10.1044/2019_JSLHR-L-RSNP-19-0031 -
Journal of Neurology, Neurosurgery, and... Jun 2018Recent evidence has fuelled the debate on the role of massed practice in the rehabilitation of chronic post-stroke aphasia. Here, we further determined the optimal daily... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Recent evidence has fuelled the debate on the role of massed practice in the rehabilitation of chronic post-stroke aphasia. Here, we further determined the optimal daily dosage and total duration of intensive speech-language therapy.
METHODS
Individuals with chronic aphasia more than 1 year post-stroke received Intensive Language-Action Therapy in a randomised, parallel-group, blinded-assessment, controlled trial. Participants were randomly assigned to one of two outpatient groups who engaged in either highly-intensive practice (Group I: 4 hours daily) or moderately-intensive practice (Group II: 2 hours daily). Both groups went through an initial waiting period and two successive training intervals. Each phase lasted 2 weeks. Co-primary endpoints were defined after each training interval.
RESULTS
Thirty patients-15 per group-completed the study. A primary outcome measure (Aachen Aphasia Test) revealed no gains in language performance after the waiting period, but indicated significant progress after each training interval (gradual 2-week -score change [CI]: 1.7 [±0.4]; 0.6 [±0.5]), independent of the intensity level applied (4-week change in Group I: 2.4 [±1.2]; in Group II: 2.2 [±0.8]). A secondary outcome measure (Action Communication Test) confirmed these findings in the waiting period and in the first training interval. In the second training interval, however, only patients with moderately-intensive practice continued to make progress (Time-by-Group interaction: =0.009, =0.13).
CONCLUSIONS
Our results suggest no added value from more than 2 hours of daily speech-language therapy within 4 weeks. Instead, these results demonstrate that even a small 2-week increase in treatment duration contributes substantially to recovery from chronic post-stroke aphasia.
Topics: Aged; Aphasia; Chronic Disease; Female; Humans; Language Therapy; Male; Middle Aged; Recovery of Function; Speech Therapy; Stroke; Time Factors; Treatment Outcome
PubMed: 29273692
DOI: 10.1136/jnnp-2017-315962 -
Restorative Neurology and Neuroscience 2023Aphasia is a debilitating language impairment, affecting millions of people worldwide. About 40% of stroke survivors develop chronic aphasia, resulting in life-long... (Review)
Review
BACKGROUND
Aphasia is a debilitating language impairment, affecting millions of people worldwide. About 40% of stroke survivors develop chronic aphasia, resulting in life-long disability.
OBJECTIVE
This review examines extrinsic and intrinsic neuromodulation techniques, aimed at enhancing the effects of speech and language therapies in stroke survivors with aphasia.
METHODS
We discuss the available evidence supporting the use of transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation, and functional MRI (fMRI) real-time neurofeedback in aphasia rehabilitation.
RESULTS
This review systematically evaluates studies focusing on efficacy and implementation of specialized methods for post-treatment outcome optimization and transfer to functional skills. It considers stimulation target determination and various targeting approaches. The translation of neuromodulation interventions to clinical practice is explored, emphasizing generalization and functional communication. The review also covers real-time fMRI neurofeedback, discussing current evidence for efficacy and essential implementation parameters. Finally, we address future directions for neuromodulation research in aphasia.
CONCLUSIONS
This comprehensive review aims to serve as a resource for a broad audience of researchers and clinicians interested in incorporating neuromodulation for advancing aphasia care.
Topics: Humans; Transcranial Direct Current Stimulation; Aphasia; Stroke; Transcranial Magnetic Stimulation; Neurological Rehabilitation
PubMed: 37980575
DOI: 10.3233/RNN-231344 -
Current Opinion in Neurology Feb 2017Early rehabilitation is recommended in many guidelines, with limited evidence to guide practice. Brain neurobiology suggests that early training, at the right dose, will... (Review)
Review
PURPOSE OF REVIEW
Early rehabilitation is recommended in many guidelines, with limited evidence to guide practice. Brain neurobiology suggests that early training, at the right dose, will aid recovery. In this review, we highlight recent trials of early mobilization, aphasia, dysphagia and upper limb treatment in which intervention is commenced within 7 days of stroke and discuss future research directions.
RECENT FINDINGS
Trials in this early time window are few. Although the seminal AVERT trial suggests that a cautious approach is necessary immediately (<24 h) after stroke, early mobility training and mobilization appear well tolerated, with few reasons to delay initiating some rehabilitation within the first week. The results of large clinical trials of early aphasia therapy are on the horizon, and examples of targeted upper limb treatments with better patient selection are emerging.
SUMMARY
Early rehabilitation trials are complex, particularly those that intervene across acute and rehabilitation care settings, but these trials are important if we are to optimize recovery potential in the critical window for repair. Concerted efforts to standardize 'early' recruitment, appropriately stratify participants and implement longer term follow-up is needed. Trial standards are improving. New recommendations from a recent Stroke Recovery and Rehabilitation Roundtable will help drive new research.
Topics: Aphasia; Humans; Patient Selection; Stroke; Stroke Rehabilitation; Time-to-Treatment
PubMed: 27845945
DOI: 10.1097/WCO.0000000000000404 -
American Journal of Speech-language... Nov 2022We present a 20-item naming test, the Severity-Calibrated Aphasia Naming Test (SCANT), that can serve as a proxy measure for an aphasia severity scale that is derived...
PURPOSE
We present a 20-item naming test, the Severity-Calibrated Aphasia Naming Test (SCANT), that can serve as a proxy measure for an aphasia severity scale that is derived from a thorough test battery of connected speech production, single-word production, speech repetition, and auditory verbal comprehension.
METHOD
We use lasso regression and cross-validation to identify an optimal subset from a set of 174 pictures to be named for prediction of aphasia severity, based on data from 200 participants with left-hemisphere stroke who were quasirandomly selected to represent the full impairment scale. Data from 20 healthy controls (i.e., participant caretakers/spouses) were also analyzed. We examine interrater reliability, test-retest reliability, sensitivity and specificity to the presence of aphasia, sensitivity to therapy gains, and external validity (i.e., correlation with aphasia severity measures) for the SCANT.
RESULTS
The SCANT has extremely high interrater reliability, and it is sensitive and specific to the presence of aphasia. We demonstrate the superiority of predictions based on the SCANT over those based on the full set of naming items. We estimate a 15% reduction in power when using the SCANT score versus the full test battery's aphasia severity score as an outcome measure; for example, to maintain the same power to detect a significant group average change in aphasia severity, a study with 25 participants using the full test battery to measure treatment effectiveness would require 30 participants if the SCANT were to be used as the testing instrument instead.
CONCLUSION
We provide a linear model to convert SCANT scores to aphasia severity scores, and we identify a change score cutoff of four SCANT items to obtain a high degree of confidence based on test-retest SCANT data and the modeled relation between SCANT and aphasia severity scores.
SUPPLEMENTAL MATERIAL
https://doi.org/10.23641/asha.21476871.
Topics: Humans; Reproducibility of Results; Aphasia; Language Tests; Stroke; Speech
PubMed: 36332139
DOI: 10.1044/2022_AJSLP-22-00071 -
Current Neurology and Neuroscience... Aug 2015The sequelae of post-stroke aphasia are considerable, with implications at the societal and personal levels. An understanding of the mechanisms of recovery of cognitive... (Review)
Review
The sequelae of post-stroke aphasia are considerable, with implications at the societal and personal levels. An understanding of the mechanisms of recovery of cognitive and language processes after stroke and the factors associated with increased risk of post-stroke language and cognitive deficits is vital in providing optimal care of individuals with aphasia and in counseling to their families and caregivers. Advances in neuroimaging facilitate the identification of dysfunctional or damaged brain tissue responsible for these cognitive/language deficits and contribute insights regarding the functional neuroanatomy of language. Evidence-based person-centered behavioral therapy remains the mainstay for rehabilitation of aphasia, although emerging evidence shows that neuromodulation is a promising adjunct to traditional therapy. These topics are discussed in this review, illustrating with recent studies from the Stroke Cognitive Outcomes and REcovery (SCORE) lab.
Topics: Animals; Aphasia; Behavior Therapy; Caregivers; Humans; Neuroimaging; Stroke; Treatment Outcome
PubMed: 26077130
DOI: 10.1007/s11910-015-0573-x -
International Journal of... Jun 2022This paper reviews several studies whose aim was to understand the nature of language recovery in chronic aphasia and identify predictors of how people may recover... (Review)
Review
This paper reviews several studies whose aim was to understand the nature of language recovery in chronic aphasia and identify predictors of how people may recover their language functions after a brain injury. Several studies that mostly draw from data collected within the Centre for Neurobiology of Language Recovery were reviewed and categorised in four aspects of language impairment and recovery in aphasia: (a) neural markers for language impairment and recovery, (b) language and cognitive markers for language impairment and recovery, (c) effective treatments and (d) predictive modelling of treatment-induced rehabilitation. Language impairment and recovery in stroke-induced aphasia is multi-factorial, including patient-specific and treatment-specific factors. A combination of these factors may help us predict treatment responsiveness even before treatment begins. Continued work on this topic will lead to a better understanding of the mechanisms that underly language impairment and treatment-induced recovery in aphasia, and, consequently, use this information to predict each person's recovery profile trajectory and provide optimal prescriptions regarding the type and dosage of treatment.
Topics: Aphasia; Humans; Language; Language Development Disorders; Recovery of Function; Stroke
PubMed: 35603543
DOI: 10.1080/17549507.2022.2075036