Article

Computer Therapy Compared With Usual Care for People With Long-Standing Aphasia Poststroke A Pilot Randomized Controlled Trial

July 2012
Stroke 43(7):1904-11

DOI:10.1161/STROKEAHA.112.650671

Source
PubMed

Authors:

Rebecca Palmer

The University of Sheffield

Pamela Enderby

The University of Sheffield

Cindy L Cooper

The University of Sheffield

Show all 12 authorsHide

The purpose of this study was to test the feasibility of conducting a randomized controlled trial to study the effectiveness of self-managed computer treatment for people with long-standing aphasia after stroke. In this pilot single-blinded, parallel-group, randomized controlled trial participants with aphasia were allocated to self-managed computer treatment with volunteer support or usual care (everyday language activity). The 5-month intervention period was followed by 3 months without intervention to investigate treatment maintenance. Thirty-four participants were recruited. Seventeen participants were allocated to each group. Thirteen participants from the usual care group and 15 from the computer treatment group were followed up at 5 months. An average of 4 hours 43 minutes speech and language therapy time and 4 hours volunteer support time enabled an average of 25 hours of independent practice. The difference in percentage change in naming ability from baseline at 5 months between groups was 19.8% (95% CI, 4.4-35.2; P=0.014) in favor of the treatment group. Participants with more severe aphasia showed little benefit. Results demonstrate early indications of cost-effectiveness of self-managed computer therapy. This pilot trial indicates that self-managed computer therapy for aphasia is feasible and that it will be practical to recruit sufficient participants to conduct an appropriately powered clinical trial to investigate the effectiveness of self-managed computer therapy for people with long-standing aphasia. Clinical Trial Registration- www.controlled-trials.com. Unique identifier: ISRCTN91534629.

Current methods in treatment of aphasia ( Métodos actuales en el tratamiento de la afasia )

Article

Full-text available

Feb 2022

Aphasia frequently leads to long-term consequences in language and communication. This paper presents an overview of current methods of aphasia treatment, as well as empirical data on their effectiveness and limitations. We surveyed literature by accessing electronic databases of Serbian libraries and by using specialized search engines on the internet. A review of the papers confirmed the existence of numerous methods in the treatment of aphasia today, which we conveniently grouped. The central place in the treatment is occupied by methods aimed at treating specific lan- guage disorders and methods specific to the type of aphasia. Methods that are complementary to language-oriented forms of therapy also need to be examined. There is a growing necessity to better define criteria for the implementation of some therapy methods. We feel that more precise definitions and a more unified methodology are needed to evaluate the efficacy of therapy methods and their verification.

Conversational Therapy through Semi-Immersive Virtual Reality Environments for Language Recovery and Psychological Well-Being in Post Stroke Aphasia

Article

Full-text available

Aug 2020
BEHAV NEUROL

Aphasia is a highly disabling acquired language disorder generally caused by a left-lateralized brain damage. Even if traditional therapies have been shown to induce an adequate clinical improvement, a large percentage of patients are left with some degree of language impairments. Therefore, new approaches to common speech therapies are urgently needed in order to maximize the recovery from aphasia. The recent application of virtual reality (VR) to aphasia rehabilitation has already evidenced its usefulness in promoting a more pragmatically oriented treatment than conventional therapies (CT). In the present study, thirty-six chronic persons with aphasia (PWA) were randomly assigned to two groups. The VR group underwent conversational therapy during VR everyday life setting observation, while the control group was trained in a conventional setting without VR support. All patients were extensively tested through a neuropsychological battery which included not only measures for language skills and communication efficacy but also self-esteem and quality of life questionnairies. All patients were trained through a conversational approach by a speech therapist twice a week for six months (total 48 sessions). After the treatment, no significant differences among groups were found in the different measures. However, the amount of improvement in the different areas was distributed over far more cognitive and psychological aspects in the VR group than in the control group. Indeed, the within-group comparisons showed a significant enhancement in different language tasks (i.e., oral comprehension, repetition, and written language) only in the VR group. Significant gains, after the treatment, were also found, in the VR group, in different psychological dimensions (i.e., self-esteem and emotional and mood state). Given the importance of these aspects for aphasia recovery, we believe that our results add to previous evidence which points to the ecological validity and feasibility of VR treatment for language recovery and psychosocial well-being. 1. Introduction Aphasia is one of the most socially disabling consequences post stroke [1–3] which manifests itself in about one-third of left brain-damaged people (30% of acute vs. 10-20% of chronic stroke patients [1]). The aphasic symptoms are heterogeneous varying in terms of severity and degree of involvement across the modalities of language, including the expression and comprehension of speech, reading, and writing [4]. Variation in the severity of expressive impairments, for example, may range from the patient’s occasional inability to find the correct word to telegraphic and much reduced speech output [5]. Thus, persons with aphasia (PWA) experience frustration and depression since their exclusion from language-dependent activities has strong implications for many aspects of their emotional condition and social status. Indeed, language difficulties determine loss of autonomy with reduced opportunities for social exchanges with friends and for practising language skills in everyday life contexts [6]. Most aphasic patients show some degree of spontaneous recovery, most notably during the first 2–3 months following stroke onset; however, studies indicate that further improvements, even in chronic patients, are possible when they are provided with an intervention (see for review [7]). The impact and the consequential implications of having aphasia for the individuals themselves and their families highlight the importance of planning efficacious treatment methods [8, 9]. The traditional aphasia therapy approaches are largely based on compensatory strategies or repetitive training of lost functions [7]. However, although there is convincing evidence that those approaches are useful, over the last years, there has been a shift from impairment-oriented language therapy to functional approaches that train language skills in more realistic contexts. A central goal here is to facilitate the successful participation of the patients in authentic conversation by increasing communicative confidence, thus, empowering PWA to improve their quality of life [10, 11]. Accordingly, the latest Cochrane review on speech and language therapy following stroke concluded that therapy should enhance functional communication in ecological contexts [7]. Indeed, a common observation regarding PWA is that they can communicate much more than their linguistic abilities would suggest. Therefore, the hypothesis has been advanced that a more ecological approach aimed at restoring the patient’s ability to communicate in different daily contexts would be proved useful in rehabilitation [12–15]. Within this approach, conversational therapy is one such treatment [12–16]. The main objective of this approach is to set up a natural conversation between the therapist and the PWA, a condition of communicative exchange, in which both speakers participate using their available communicative resources [14, 15]. Within this therapeutic approach, not only language but also any intentional action (e.g., gesturing, drawing) can be used to communicate. The therapeutic goal shifts from a purely analytic treatment aimed at the recovery of the damaged linguistic processes, still used in the traditional approach, to a global approach. The latter considers the ability of the PWA to communicate as a whole through strengthening his/her residual communicative functions [12–16]. In these last years, scientific advancements in language conceptualization and the progress of new technologies have made new tools available for professional therapists and educators. Digital technologies offer exciting opportunities to PWAs who live with long-term communication deficits (see for review [17]). Among these technologies, computer therapies deliver individually tailored exercises for training a range of language skills, including word retrieval [18, 19], sentence building [20, 21], and language comprehension [22]. The StepByStep (PLOS) computer program includes over 10,000 language exercises ranging from listening to writing words or producing sentences [17, 19]. It was shown that patients who received StepByStep training achieved greater improvement in naming ability compared with patients who received the standard speech and language therapy [19]. A study that investigated Multicue as a rehabilitation program demonstrated significant improvement in naming abilities measured through the Boston Naming Test in patients who received the training; however, no significant improvement was shown in verbal communication skills [18, 23, 24]. Overall, these studies suggested that independent computerized therapies can be as effective as clinician-guided therapies [24]. However, most of these studies exhibited a positive effect on word finding in picture naming tasks but not on communicative abilities [18, 23, 24]. Additionally, iPad-based aphasia rehabilitation treatments have been investigated but, as for computer therapies, most of the findings investigated the impact only on language functions [25–28]. Among the applied technologies, an area that particularly merits exploration is virtual reality (VR). Development of VR applications for rehabilitation of aphasia is still in its early stages ([29–32]; see for a review [17]). This involves a computer-generated simulation of 3D environments with which the user can experience a semi-immersive interaction that may encourage language practice in real context communication settings. Typically, an individual entering a virtual environment feels a part of this world and he/she has the opportunity to interact with it almost as he/she would do in the real world. Uses of VR in healthcare are widespread, ranging from the treatment of physical impairments [33, 34], post traumatic stress disorders [35], and anxiety [36, 37]. Virtual reality applications have been also explored on different communication disorders such a speaking phobias [38], stuttering [39], and autism [40, 41]. However, to date, the use of VR for language recovery in aphasia has been limited. Stark et al. [42] developed a virtual house to promote individual language practice. In Aphasia Script [43], therapy is based on the oral production of scripts, which are short functional dialogs structured around communication of everyday activities. Script treatment can be delivered by a virtual therapist (VT) through a computer or by a real therapist. A randomized controlled cross-over study using Aphasia Script was conducted to investigate the effect of high or low cuing on treatment outcomes over time [43]. Eight participants were recruited and randomized to receive intensive computer-based script training differing in the amount of high or low cuing provided during treatment. In the high cue treatment condition, participants could hear the virtual therapist (VT) during listening, choral reading, and reading aloud, with auditory cues (therapist speaking) and visual cues (therapist’s mouth movements) available at the start, during, and after practice. In the low cue condition, they received visual and auditory cues when listening to the script being read aloud initially and after practice, but did not receive auditory and visual support during sentence practice. Performance was measured by averaging the sentence level word accuracy of participants’ production of ten sentences (ten words in length) during each assessment session. Accuracy of words were rated using a previously validated six-point scale, and the overall session score expressed on a scale from 0 to 100%. Training resulted in significant gains in script acquisition with maintenance of skills at three and six weeks posttreatment. Differences between cuing conditions were not significant. Three weeks of computer-based script training resulted in increased accuracy and rate of script production. The mean baseline performance was 50.0 (26.4)% for accuracy and 23.7 (20.6) for rate (words per minute, WPM). At the end of training, it had improved to 77.8 (19.6)% and 60.3 (30.5) WPM for accuracy and rate, respectively. Moreover, although there was a slight drop in performance noted at both three weeks and six weeks posttreatment, the decreases were small. At three weeks posttreatment, the mean scores for accuracy were 72.2 (22.4) and the mean scores for rate were 55.2 (34.0). By six weeks posttreatment, these scores had declined slightly to 68.6 (24.7) for accuracy and 51.4 (35.8) for rate [43]. The Web Oral Reading for Language in Aphasia (ORLA, Rehabilitation Institute of Chicago) [44] is a therapy program where patients repeatedly read aloud sentences, first in unison with a clinician and then independently. The program was developed to improve the patient’s reading comprehension skills by providing practice in phonological and semantic reading routes. Following a no-treatment period, twenty-five individuals with chronic nonfluent aphasia were randomly assigned to receive twenty-four sessions of ORLA, 1–3 times per week, either by computer () or by a speech language pathologist () (SLP-ORLA). Results showed that the mean change in the Western Aphasia Battery-Aphasia Quotient scores (the primary outcome measure) from pre- to posttreatment was 3.29 () for the eleven participants receiving computer ORLA. In comparison, the mean change during the no-treatment phase from baseline to posttreatment was only −0.4. Student -tests were used to compute the change from pretreatment to posttreatment between the computer ORLA and SLP-ORLA groups. No significant differences were found on any of the outcome measures ( values ranged from 0.2 to 0.6), suggesting good compatibility and feasibility of the VR version [45]. Sentactics (Sentactics Corporation, Concord, CA, USA) is a linguistic treatment which aims at improving sentence production and comprehension deficits through a virtual clinician. Patients are trained repeating and reading sentences and describing pictures presented on the screen. Thompson et al. [20] conducted a study to test the efficacy of Sentactics as an aphasia rehabilitation tool. Computer-delivered Sentactics was compared with a clinician-delivered therapy. Results showed that patients who received Sentactics training significantly improved in production and comprehension for both trained (0% to 90% production, 0% to 30% comprehension) and untrained sentences (0% to 30% production, 0% to 15% comprehension) [20]. More recently, a multiuser virtual world called EVA Park was designed for PWA. The authors wanted to investigate whether virtual environments would enable people with moderate aphasia to practice speech successfully with one or more conversational partners [32]. The results collected in twenty PWA, after five weeks of therapy intervention, revealed that the VR experience offered participants rich insights into aspects which go beyond the therapeutic outcomes. Indeed, PWAs experienced conversational initiative, positive emotional, and social outcomes and their therapeutic benefits were well-maintained on a measure of everyday communication (mean scores across the three time points: week 1: 6.5 vs. week 7: 7.2 vs. week 13: 7.4, Communication Activities of Daily Living (CADL-2) test). However, as also observed by the authors [32], one limitation of their study was related to the lack of a control group inclusion which should have undergone a different treatment. This allows no conclusions to be drawn about the relative merits of the therapy delivered in VR compared to “conventional” face to face therapy. Kurland et al. [46] investigated the effects of a tablet-based home practice program with telepractice on treatment outcomes in twenty-one individuals with chronic aphasia. The main outcome measure was percent accuracy on naming sets of treated and untreated objects and actions. Overall, results showed that home practice was effective for all participants with severity moderating treatment effects, such that individuals with the most severe aphasia made and maintained fewer gains (difference between post- and pretreatment in naming accuracy, severe: 0.067 vs. moderate: 0.057 vs. mild: 0.123 for treated items; severe: 0.099 vs. moderate: 0.157 vs. mild: 0.138 for untreated items). Marshall et al. [47] reported two single case studies exploring the impact of daily language stimulation delivered through EVA Park platform [32] for treated and untreated word production, connected speech, and functional communication. After the therapy, outcomes varied across the different test measurements. The noun therapy significantly improved the naming of treated words in case study 1 but not in case study 2 (case 1, pre-posttreatment: 25 out of 50 items vs. 44 out of 50 items), with good maintenance after five weeks (case 1, 41 out of 50 items). There was no generalisation to untreated words (case 1, pre-posttreatment 27 out of 50 items vs. 25 out of 50 items), connected speech, or functional communication. Within a case series (), Carragher et al. [48] explored the effect of storytelling intervention delivered in EVA Park [32]. The intervention dose was four sessions per week for a total of five weeks (twenty hours total). Following intervention, two participants (“Ange” and “Sally”) showed substantial increases in the percentage of correct content words produced (Ange: 36.5%; Sally: 35.5%). The third participant demonstrated a more modest change with an increase of 12.1%. Very recently, Palmer et al. [49] reported the first multicentre randomised controlled trial (BIG CACTUS) in patients with post stroke chronic aphasia (>6 months) to assess both the clinical and cost-effectiveness of self-managed computerised speech and language therapy (CSLT). Two hundred and seventy-five participants were randomly assigned to either six months of usual care (usual care group, ), daily self-managed CSLT plus usual care (CSLT group, ), or attention control plus usual care (attention control group, ). Coprimary outcomes were changes, between baseline and 6 months after randomization, in lexical retrieval of personally relevant words in a picture naming test and in functional communication ability measured with the use of Therapy Outcome Measures (TOMs). The key secondary outcome was change in self-perception of communication and social participation measured through the Communication Outcomes After Stroke (COAST) questionnaire self-rated by the patient. Word finding improvement was 16. 2% higher in the CSLT group than in the usual care group and 14. 4% higher than in the attention control group. Improvement in word finding was maintained 6 months after the intervention period. However, CSLT did not have an effect on conversation, self-perceived improvements in everyday communication, social participation, and quality of life [49]. Maresca et al. [50] employed a VR tablet in order to evaluate the effectiveness of a rehabilitation training for aphasia. Thirty PWA were randomly assigned into either the control or the experimental group. The study lasted six months and included two phases. During the first phase, the experimental group was trained through the VR tablet, while the control group underwent traditional therapy. In the second phase, the experimental group was discharged but it was provided with the VR tablet, while the control group was assigned to community services. Results showed that the experimental group improved in all investigated tasks except in writing, while the control group improved only in comprehension, depression, and quality of life. In summary, although in the field of aphasia rehabilitation, technical devices have begun to be employed, to date, digital versions of traditional language therapy exercises have been mostly used [17]. Very few studies have explored digital applications, including VR settings, for conversation in social interaction (but see [33, 51, 52]). More importantly, none of the cited studies has investigated the impact of VR technology on the patient’s psychological well-being [but see 49]. Here, we report a video-based conversational training approach which makes use of semi-immersive VR environments to investigate their therapeutic benefits in enhancing language skills, communication efficacy, and psychosocial aspects (i.e., the self-esteem level; the patient’s emotional, health, and humoral states) in a group of eighteen nonfluent chronic PWA. The efficacy of the VR approach was compared to the results of a matched control group of eighteen PWA who underwent the same conversational training without VR support. 1.1. Aims The study addressed the following research questions (RQs): RQ1: does conversational therapy delivered via semi-immersive VR environments enhance language recovery in chronic post stroke aphasia? RQ2: do therapy benefits generalize to measures of communication efficacy and psychological well-being? RQ3: is VR therapy equivalent or more effective than conventional training? 1.2. Hypothesis In line with previous literature [8, 13, 14] which suggests that language treatment should enhance functional communication in ecological contexts, we hypothesize that conversational therapy combined with VR would be effective for aphasia. Since a central aspect of conversational approach is to set up communicative exchanges between the therapist and the patient in ecological contexts [15, 16], we further believe that treatment benefit would generalize to communication efficacy and, possibly, to psychological well-being. 2. Materials and Methods 2.1. Participants All patients were recruited from the neurological departments of different hospitals in Turin. Seventy-six have completed their speech therapy cycle and contacted the Experimental Laboratory of Aphasia of the Fondazione Carlo Molo Onlus in Turin in order to participate as volunteers in the research. A preliminary neuropsychological assessment was handled by an independent neuropsychologist who was blinded to the research. The inclusion criteria were fluent users of Italian, premorbidly right handed, a diagnosis of aphasia due to a single left hemisphere stroke occurring more than six months prior to the study; absence of cognitive impairment; ability to follow instructions; no hemispatial neglect; no articulatory disorder; no uncorrected visual impairment (self-report); and no hearing loss (screened via pure tone audiometry). Since our treatment was based on a conversational therapy approach aimed at enhancing verbal communication, we selected only nonfluent patients. Patients were not enrolled if they had a premorbid speech and language disorder caused by a neurological deficit other than stroke. Twenty patients were excluded because they did not meet the criteria. Fifteen people gave up for logistic reasons. Five had another stroke during the enrollment period. The thirty-six patients selected were randomly assigned to two different conditions by a researcher not involved in the research, using the Research Randomizer (https://www.randomizer.org/), a free web-based service that offers instant random sampling and random assignment. All have age between 32 and 77 years (59.75+/-11.21) with an educational level of 5 to 18 years (11.25+/-3.54). Eighteen patients were assigned to the experimental group and eighteen to the control group. In order to obtain more accurate results, the study included a sample size that would allow parametric statistics to be applied to the data. Table 1 provides background details for the participants. Participants Age Sex Educational level Time post onset Etiology S1 71 M 18 30 Frontotemporal hemorrhage S2 50 F 8 28 Frontoparietal ischemia S3 72 M 8 30 Frontotemporal ischemia S4 68 M 13 40 Frontotemporal ischemia S5 69 F 8 41 Frontal ischemia S6 49 F 18 48 Temporoparietal hemorrhage S7 53 M 13 36 Frontotemporal ischemia S8 53 M 13 34 Frontoparietal ischemia S9 71 M 13 54 Temporal ischemia S10 32 M 15 40 Basal ganglia hemorrhage S11 37 M 11 35 Temporoparietal hemorrhage S12 51 M 13 30 Frontotemporal ischemia S13 61 M 8 24 Temporoparietal ischemia S14 48 M 8 24 Frontal hemorrhage S15 72 F 5 30 Temporooccipital hemorrhage S16 48 M 8 40 Frontal hemorrhage S17 75 M 13 60 Temporoparietal ischemia S18 70 M 8 30 Frontoparietal ischemia S19 60 M 18 40 Frontotemporoparietal ischemia S20 69 M 13 36 Frontotemporal ischemia S21 56 F 13 35 Frontotemporal ischemia S22 60 F 8 28 Temporal ischemia S23 61 F 13 40 Frontotemporal ischemia S24 53 M 13 42 Frontotemporal ischemia S25 47 F 18 50 Frontotemporal ischemia S26 61 M 13 54 Frontotemporal ischemia S27 63 F 8 52 Frontotemporal hemorrhage S28 70 F 8 60 Frontotemporal ischemia S29 61 M 13 70 Frontotemporal ischemia S30 38 M 13 54 Temporooccipital ischemia S31 69 M 8 60 Frontotemporal ischemia S32 70 M 8 58 Temporoparietal hemorrhage S33 63 M 8 56 Frontotemporal ischemia S34 60 M 9 52 Frontal ischemia S35 77 F 13 50 Temporoparietal ischemia S36 63 F 7 48 Temporoparietal ischemia

Computerised speech and language therapy or attention control added to usual care for people with long-term post-stroke aphasia: the Big CACTUS three-arm RCT

Article

Apr 2020

Background People with aphasia may improve their communication with speech and language therapy many months/years after stroke. However, NHS speech and language therapy reduces in availability over time post stroke. Objective This trial evaluated the clinical effectiveness and cost-effectiveness of self-managed computerised speech and language therapy to provide additional therapy. Design A pragmatic, superiority, single-blind, parallel-group, individually randomised (stratified block randomisation, stratified by word-finding severity and site) adjunct trial. Setting Twenty-one UK NHS speech and language therapy departments. Participants People with post-stroke aphasia (diagnosed by a speech and language therapist) with long-standing (> 4 months) word-finding difficulties. Interventions The groups were (1) usual care; (2) daily self-managed computerised word-finding therapy tailored by speech and language therapists and supported by volunteers/speech and language therapy assistants for 6 months plus usual care (computerised speech and language therapy); and (3) activity/attention control (completion of puzzles and receipt of telephone calls from a researcher for 6 months) plus usual care. Main outcome measures Co-primary outcomes – change in ability to find treated words of personal relevance in a bespoke naming test (impairment) and change in functional communication in conversation rated on the activity scale of the Therapy Outcome Measures (activity) 6 months after randomisation. A key secondary outcome was participant-rated perception of communication and quality of life using the Communication Outcomes After Stroke questionnaire at 6 months. Outcomes were assessed by speech and language therapists using standardised procedures. Cost-effectiveness was estimated using treatment costs and an accessible EuroQol-5 Dimensions, five-level version, measuring quality-adjusted life-years. Results A total of 818 patients were assessed for eligibility and 278 participants were randomised between October 2014 and August 2016. A total of 240 participants (86 usual care, 83 computerised speech and language therapy, 71 attention control) contributed to modified intention-to-treat analysis at 6 months. The mean improvements in word-finding were 1.1% (standard deviation 11.2%) for usual care, 16.4% (standard deviation 15.3%) for computerised speech and language therapy and 2.4% (standard deviation 8.8%) for attention control. Computerised speech and language therapy improved word-finding 16.2% more than did usual care (95% confidence interval 12.7% to 19.6%; p < 0.0001) and 14.4% more than did attention control (95% confidence interval 10.8% to 18.1%). Most of this effect was maintained at 12 months ( n = 219); the mean differences in change in word-finding score increased by 12.7% (95% confidence interval 8.7% to 16.7%) more words in the computerised speech and language therapy group ( n = 74) than in the usual-care group ( n = 84) and increased by 9.3% (95% confidence interval 4.8% to 13.7%) in the computerised speech and language therapy group than in the attention control group ( n = 61). Computerised speech and language therapy did not show significant improvements on Therapy Outcome Measures or Communication Outcomes After Stroke compared with usual care or attention control. Primary cost-effectiveness analysis estimated an incremental cost per participant of £732.73 (95% credible interval £674.23 to £798.05). The incremental quality-adjusted life-year gain was 0.017 for computerised speech and language therapy compared with usual care, but its direction was uncertain (95% credible interval –0.05 to 0.10), resulting in an incremental cost-effectiveness ratio of £42,686 per quality-adjusted life-year gained. For mild and moderate word-finding difficulty subgroups, incremental cost-effectiveness ratios were £22,371 and £28,898 per quality-adjusted life-year gained, respectively, for computerised speech and language therapy compared with usual care. Limitations This trial excluded non-English-language speakers, the accessible EuroQol-5 Dimensions, five-level version, was not validated and the measurement of attention control fidelity was limited. Conclusions Computerised speech and language therapy enabled additional self-managed speech and language therapy, contributing to significant improvement in finding personally relevant words (as specifically targeted by computerised speech and language therapy) long term post stroke. Gains did not lead to improvements in conversation or quality of life. Cost-effectiveness is uncertain owing to uncertainty around the quality-adjusted life-year gain, but computerised speech and language therapy may be more cost-effective for participants with mild and moderate word-finding difficulties. Exploring ways of helping people with aphasia to use new words in functional communication contexts is a priority. Trial registration Current Controlled Trials ISRCTN68798818. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 19. See the NIHR Journals Library website for further project information. The Tavistock Trust for Aphasia provided additional support to enable people in the control groups to experience the intervention after the trial had ended.

Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS) : a multicentre, single-blinded, randomised controlled trial

Article

Full-text available

Sep 2019
LANCET NEUROL

Background: Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone. Methods: In this pragmatic, superiority, three-arm, individually randomised, single-blind, parallel group trial, patients were recruited from 21 speech and language therapy departments in the UK. Participants were aged 18 years or older and had been diagnosed with aphasia post-stroke at least 4 months before randomisation; they were excluded if they had another premorbid speech and language disorder caused by a neurological deficit other than stroke, required treatment in a language other than English, or if they were currently using computer-based word-finding speech therapy. Participants were randomly assigned (1:1:1) to either 6 months of usual care (usual care group), daily self-managed CSLT plus usual care (CSLT group), or attention control plus usual care (attention control group) with the use of computer-generated stratified blocked randomisation (randomly ordered blocks of sizes three and six, stratified by site and severity of word finding at baseline based on CAT Naming Objects test scores). Only the outcome assessors and trial statistician were masked to the treatment allocation. The speech and language therapists who were doing the outcome assessments were different from those informing participants about which group they were assigned to and from those delivering all interventions. The statistician responsible for generating the randomisation schedule was separate from those doing the analysis. Co-primary outcomes were the change in ability to retrieve personally relevant words in a picture naming test (with 10% mean difference in change considered a priori as clinically meaningful) and the change in functional communication ability measured by masked ratings of video-recorded conversations, with the use of Therapy Outcome Measures (TOMs), between baseline and 6 months after randomisation (with a standardised mean difference in change of 0·45 considered a priori as clinically meaningful). Primary analysis was based on the modified intention-to-treat (mITT) population, which included randomly assigned patients who gave informed consent and excluded those without 6-month outcome measures. Safety analysis included all participants. This trial has been completed and was registered with the ISRCTN, number ISRCTN68798818. Findings: From Oct 20, 2014, to Aug 18, 2016, 818 patients were assessed for eligibility, of which 278 (34%) participants were randomly assigned (101 [36%] to the usual care group; 97 [35%] to the CSLT group; 80 [29%] to the attention control group). 86 patients in the usual care group, 83 in the CSLT group, and 71 in the attention control group contributed to the mITT. Mean word finding improvements were 1·1% (SD 11·2) in the usual care group, 16·4% (15·3) in the CSLT group, and 2·4% (8·8) in the attention control group. Word finding improvement was 16·2% (95% CI 12·7 to 19·6; p<0·0001) higher in the CSLT group than in the usual care group and was 14·4% (10·8 to 18·1) higher than in the attention control group. Mean changes in TOMs were 0·05 (SD 0·59) in the usual care group (n=84), 0·04 (0·58) in the CSLT group (n=81), and 0·10 (0·61) in the attention control group (n=68); the mean difference in change between the CSLT and usual care groups was -0·03 (-0·21 to 0·14; p=0·709) and between the CSLT and attention control groups was -0·01 (-0·20 to 0·18). The incidence of serious adverse events per year were rare with 0·23 events in the usual care group, 0·11 in the CSLT group, and 0·16 in the attention control group. 40 (89%) of 45 serious adverse events were unrelated to trial activity and the remaining five (11%) of 45 serious adverse events were classified as unlikely to be related to trial activity. Interpretation: CSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. Funding: National Institute for Health Research, Tavistock Trust for Aphasia.

Estimating the cost and value of functional changes in communication ability following telepractice treatment for aphasia

Article

Full-text available

Sep 2021
PLOS ONE

Context Aphasia is a post-stroke condition that can dramatically impact a person with aphasia’s (PWA) communication abilities. To date, few if any studies have considered the cost and cost-effectiveness of functional change in aphasia nor considered measures of patient’s value for aphasia treatment. Objective To assess the cost, cost-effectiveness, and perceived value associated with improved functional communication in individuals receiving telerehabilitation treatment for aphasia. Design Twenty PWA completed between 5 and 12 telehealth rehabilitation sessions of 45–60 minutes within a 6-week time frame using a Language-Oriented Treatment (LOT) designed to address a range of language issues among individuals with aphasia. National Outcomes Measures (NOMS) comprehension and verbal expression and the ASHA Quality of Communication Life (QCL) were completed prior to and at the completion of rehabilitation to obtain baseline and treatment measures. Results Age, education, and race are significantly correlated with improvement in the NOMS verbal expression. African Americans (OR = 2.0917) are twice as likely as Whites to experience improvement after treatment. The likelihood of improvement also increases with each additional year of education (OR = 1.002) but decrease with age (OR = 0.9463). A total of 15 PWA showed improvement in NOMS comprehension and nine patients showed improvement in NOMS verbal expression. Improving patients attended between five and 12 treatment sessions. The average cost of improvement in NOMS comprehension was $1,152 per patient and NOMS verbal expression was $1,128 per patient with individual treatment costs varying between $540 and $1,296. However, on average, the monetary equivalent in patient’s improved QCL was between $1,790.39 to $3,912,54—far exceeding the financial cost of treatment. Conclusions When measuring the functional improvement of patients with aphasia, patient’s quality of communication life received from treatment exceeded financial cost of services provided.

The feasibility, usability and acceptability of a tablet-based aphasia therapy in the acute phase following stroke

Article

Dec 2020
J COMMUN DISORD

Question Independent practice via an application with a language exercise program for aphasia, as an add-on to conventional care can be a good solution to intensify aphasia therapy. The aim of this prospective trial was to investigate the feasibility, usability and acceptability of the newly-developed aphasia exercise program in the ‘Speech Therapy App (STAPP)’ in the acute phase post-stroke. Methods All eligible people with aphasia following stroke (< 2 weeks post-stroke) admitted to the Stroke Unit of Ghent University Hospital were recruited in this prospective clinical trial between September 2018 and December 2019. After linguistic assessments and two short training sessions, participants were asked to practice independently with ‘STAPP’ for at least 30 minutes/day during hospitalization. Exercises were individually tailored and adjusted if necessary. Outcome was measured by recruitment, adherence and retention rates, usability questionnaires and a visual analogue scale for satisfaction. Results Twenty-five (mean age 65 years (SD = 17), 14 females) of 31 eligible people with aphasia were enrolled in this trial (recruitment rate = 81%). All participants but one (23/24) practiced with the language app until the end of hospitalization (retention rate = 96%). Ten participants practiced at least 30 minutes/day (adherence rate = 42%). Participants reported they learned to work quickly with the app (92%; agreed/totally agreed), the app was easy to use (88%), they could work independently (79%), practiced their language (67%) and wanted to continue working with the app at home (79%). Acceptability was high (median satisfaction rate 91%; IQR = 75–100). Conclusion The aphasia exercise program in ‘STAPP’ is feasible to use as an additional rehabilitation tool along with standard of care in the acute phase post-stroke. Further research is needed to assess the efficacy.

Self-managed, computerised word finding therapy as an add-on to usual care for chronic aphasia post-stroke: An economic evaluation

Article

Full-text available

Nov 2020

Objective To examine the cost-effectiveness of self-managed computerised word finding therapy as an add-on to usual care for people with aphasia post-stroke. Design Cost-effectiveness modelling over a life-time period, taking a UK National Health Service (NHS) and personal social service perspective. Setting Based on the Big CACTUS randomised controlled trial, conducted in 21 UK NHS speech and language therapy departments. Participants Big CACTUS included 278 people with long-standing aphasia post-stroke. Interventions Computerised word finding therapy plus usual care; usual care alone; usual care plus attention control. Main measures Incremental cost-effectiveness ratios (ICER) were calculated, comparing the cost per quality adjusted life year (QALY) gained for each intervention. Credible intervals (CrI) for costs and QALYs, and probabilities of cost-effectiveness, were obtained using probabilistic sensitivity analysis. Subgroup and scenario analyses investigated cost-effectiveness in different subsets of the population, and the sensitivity of results to key model inputs. Results Adding computerised word finding therapy to usual care had an ICER of £42,686 per QALY gained compared with usual care alone (incremental QALY gain: 0.02 per patient (95% CrI: −0.05 to 0.10); incremental costs: £732.73 per patient (95% CrI: £674.23 to £798.05)). ICERs for subgroups with mild or moderate word finding difficulties were £22,371 and £21,262 per QALY gained respectively. Conclusion Computerised word finding therapy represents a low cost add-on to usual care, but QALY gains and estimates of cost-effectiveness are uncertain. Computerised therapy is more likely to be cost-effective for people with mild or moderate, as opposed to severe, word finding difficulties.

Design Considerations for Clinical Trials in Aphasia

Article

Full-text available

Sep 2020

Rebecca Palmer

The use of the randomised controlled trial (RCT) design to evaluate the effectiveness of new interventions in aphasia has increased in recent years in response to calls for high quality evidence of the effectiveness of interventions for this population. This view-point article highlights some of the important considerations when designing a trial for an aphasia intervention, illustrated with decisions made when designing the Big CACTUS RCT for self-managed computer-based word finding therapy in aphasia. Considerations outlined include whether an RCT is needed, readiness for conducting an RCT, choice of comparators, randomisation options, blinding/masking, selection of outcome measures, pragmatic versus explanatory approaches, and fidelity measurement.

Lavoie et al. Amélioration de la dénomination orale de mots fonctionnels via une thérapie auto-administrée

Chapter

Full-text available

Dec 2017

Résumé. L’aphasie est un trouble acquis du langage qui nécessite des services de réadaptation orthophonique à long terme. Cependant, en raison de considérations financières et logistiques, peu de services sont généralement offerts aux personnes qui souffrent d’aphasie chronique au Québec et au Canada. Dans ce contexte, les nouvelles technologies, comme la tablette électronique, offrent de nouvelles opportunités pour permettre aux personnes aphasiques de maximiser leur potentiel de rééducation. L’objectif de la présente étude était donc de mesurer l’efficacité d’une thérapie sémantique-phonologique auto-administrée à l'aide d'une tablette électronique pour l’amélioration de la dénomination de mots fonctionnels chez P.R., une participante de 73 ans souffrant d’aphasie chronique. Un devis de type ABA avec lignes de base multiples a été utilisé afin de comparer la performance en dénomination orale pour trois listes équivalentes : une liste traitée comprenant des mots choisis en collaboration avec P.R. pour leur valeur fonctionnelle, une liste traitée comprenant des mots choisis selon l’approche classique à partir d’une banque d’images et une liste non traitée. Les résultats démontrent une amélioration significative de la performance en dénomination pour les deux listes traitées ainsi qu’un maintien des gains jusqu’à 1 mois après l’arrêt du traitement. De plus, des indices quant à la supériorité des items fonctionnels vs choisis selon l’approche classique sont observés. D’autres études sont nécessaires afin de confirmer les résultats de cette étude de cas qui présente une vision novatrice de la rééducation orthophonique en aphasie chronique. Abstract Aphasia is an acquired deficit of language requiring long-term rehabilitation in speech-language therapy. However, because of financial and logistical considerations, services are often limited for people with chronic aphasia in Quebec and in Canada. In this context, new technologies, such as smart tablet, offer new opportunities to allow people with aphasia to maximize their rehabilitation potential. The aim of this study was to measure the efficacy of a self-administered semanticphonological treatment delivered with a smart tablet to improve naming of functional words in P.R., a 73-year-old woman with chronic aphasia. An ABA multiple baseline design was used to compare the performance in oral naming on three equivalent lists : trained words chosen with P.R. for their functional value, trained words chosen according to the classical approach and, non trained words. Results show a significant improvement of naming for the two trained lists with maintenance of the gains up to 1 month post-treatment. Moreover, there are indications of the superiority of recovery for functional words. More studies are needed to confirm the results of this study in which an innovative vision of language rehabilitation in chronic aphasia was presented.

Uncovering the Potential for a Weakly Supervised End-to-End Model in Recognising Speech from Patient with Post-Stroke Aphasia

Conference Paper

Jan 2023

Measuring Aphasia-Related Quality of Life: Efficiency and Cost of Change

Article

Nov 2022

Purpose Changes in quality of life (QoL) in persons with aphasia (PWA) has emerged as a key metric of aphasia treatment effectiveness. Several tools have been designed to measure aphasia related QoL and offer the appropriate compensation for communication issues that frequently exclude persons with aphasia (PWA) from participation of such studies. The purpose of this study was to measure post–aphasia treatment change in QoL and calculate the efficiency and cost of QoL change. Method In this study, we measured change in aphasia-related QoL as a metric of post–aphasia treatment efficiency using the American Speech-Language-Hearing Association Quality of Communication Life Scale. We also calculated the associated cost of that change in relationship with the change of aphasia impairment using a sample of PWA who received community-based telerehabilitation. Cost of QoL improvement from the intervention was calculated accounting for differences in age, time post onset, aphasia severity, and aphasia type. Results PWA that exhibited more severe aphasia impairment experienced larger QoL improvement than those at lower impairment levels. Similarly, the average cost of improvement in QoL was lower for those more severe aphasia. Conclusions Changes in aphasia-related QoL captures the impact of communication disorders on QoL, and the cost associated with the change. Measurement of aphasia-related QoL will allow clinicians and researchers to measure aphasia treatment outcomes and the cost effectiveness of those treatments using a commonly reported patient outcome—QoL.

Effects of a new speech support application on intensive speech therapy and changes in functional brain connectivity in patients with post-stroke aphasia

Article

Full-text available

Sep 2022
FRONT HUM NEUROSCI

Aphasia is a language disorder that occurs after a stroke and impairs listening, speaking, reading, writing, and calculation skills. Patients with post-stroke aphasia in Japan are increasing due to population aging and the advancement of medical treatment. Opportunities for adequate speech therapy in chronic stroke are limited due to time constraints. Recent studies have reported that intensive speech therapy for a short period of time or continuous speech therapy using high-tech equipment, including speech applications (apps, can improve aphasia even in the chronic stage. However, its underlying mechanism for improving language function and its effect on other cognitive functions remains unclear. In the present study, we investigated whether intensive speech therapy using a newly developed speech support app could improve aphasia and other cognitive functions in patients with chronic stroke. Furthermore, we examined whether it can alter the brain network related to language and other cortical areas. Thus, we conducted a prospective, single-comparison study to examine the effects of a new speech support app on language and cognitive functions and used resting state functional MRI (rs-fMRI) regions of interest (ROI) to ROI analysis to determine changes in the related brain network. Two patients with chronic stroke participated in this study. They used the independent speech therapy system to perform eight sets of 20 randomly presented words/time (taking approximately 20 min), for 8 consecutive weeks. Their language, higher cognitive functions including attention function, and rs-fMRI, were evaluated before and after the rehabilitation intervention using the speech support app. Both patients had improved pronunciation, daily conversational situations, and attention. The rs-fMRI analysis showed increased functional connectivity of brain regions associated with language and attention related areas. Our results show that intensive speech therapy using this speech support app can improve language and attention functions even in the chronic stage of stroke, and may be a useful tool for patients with aphasia. In the future, we will conduct longitudinal studies with larger numbers of patients, which we hope will continue the trends seen in the current study, and provide even stronger evidence for the usefulness of this new speech support app.

Understanding the Economics of Aphasia: Recent Findings from Speech and Language Research

Article

Jun 2022

In recent years, stakeholders engaged in the study, treatment, and understanding of aphasia outcomes have emphasized the need for greater transparency regarding the economics of aphasia rehabilitation. Most notably, third-party payers and clinicians have a keen interest in understanding the resources used to treat aphasia, particularly the cost-effectiveness and value of aphasia treatments. In this article, we review the current literature related to the economic burden of aphasia and the cost and cost-effectiveness of aphasia treatments. To date, relatively few scholars have attempted to study the efficiency, scale, and scope related to the economics of aphasia and the cost-effectiveness of aphasia treatment. While studies of the cost-effectiveness of aphasia treatments have shown rehabilitative treatments conform to established quality and cost benchmarks, the continued progress and developments in the treatment of aphasia and measurement of clinical outcomes has left many areas unstudied. We highlight the need for greater emphasis on the cost-effectiveness of aphasia treatments in addition to the traditional focus on the efficacy of treatment outcomes.

Applying adaptive distributed practice to self-managed computer-based anomia treatment: A single-case experimental design

Article

Jul 2022
J COMMUN DISORD

Introduction : There is a pressing need to improve computer-based treatments for aphasia to increase access to long-term effective evidence-based interventions. The current single case design incorporated two learning principles, adaptive distributed practice and stimuli variability, to promote acquisition, retention, and generalization of words in a self-managed computer-based anomia treatment. Methods : Two participants with post-stroke aphasia completed a 12-week adaptive distributed practice naming intervention in a single-case experimental design. Stimuli variability was manipulated in three experimental conditions: high exemplar variability, low exemplar variability, and verbal description prompt balanced across 120 trained words. Outcomes were assessed at 1-week, 1-month, and 3-months post-treatment. Statistical comparisons and effect sizes measured in the number of words acquired, generalized, and retained were estimated using Bayesian generalized mixed-effect models. Results : Participants showed large and robust acquisition, generalization, and retention effects. Out of 120 trained words, participant 1 acquired ∼77 words (trained picture exemplars) and ∼63 generalization words (untrained picture exemplars of treated words). Similarly, participant 2 acquired ∼57 trained words and ∼48 generalization words. There was no reliable change in untrained control words for either participant. Stimuli variability did not show practically meaningful effects. Conclusions : These case studies suggest that adaptive distributed practice is an effective method for re-training more words than typically targeted in anomia treatment research (∼47 words on average per Snell et al., 2010). Generalization across experimental conditions provided evidence for improved lexical access beyond what could be attributed to simple stimulus-response mapping. These effects were obtained using free, open-source flashcard software in a clinically feasible, asynchronous format, thereby minimizing clinical implementation barriers. Larger-scale clinical trials are required to replicate and extend these effects.

Comic Spin: A Comic Creation Tool Enabling Self-Expression for People with Aphasia

Article

Feb 2022

Comics, with their highly visual format, offer a promising opportunity for people who experience challenges with language to express humour and emotion. However, comic creation tools are not designed to be accessible to people with language impairments such as aphasia. We report the design and exploration of Comic Spin , an app for people with aphasia that supports the creation of comic strips by constraining the creative space. We explored the use of Comic Spin in two studies involving creative workshops. Findings showed that people were able to use Comic Spin successfully to create a range of narrative, humorous and subversive comic strips, and that these enabled people to self-express in ways that went beyond the content of the comic strips themselves.

ICT usage in aphasia rehabilitation – beliefs, biases, and influencing factors from the perspectives of speech and language therapists

Article

Full-text available

Feb 2022

Background The use of digital technology is promoted as an efficient route for the delivery of intensive speech and language therapy in aphasia rehabilitation. Research has begun to explore the views of people with aphasia (PwA) in relation to Information and Communication Technology (ICT) usage in the management of aphasia but there is less consideration of the prescribers’ views, i.e., speech and language therapists (SLTs). Aims We aimed to explore SLTs’ views of ICT use in aphasia management and identify factors that influence their decisions to accept and integrate ICT in aphasia rehabilitation. In addition, we considered the findings in the context of the Unified Theory of Acceptance and Use of Technology (Venkatesh, Morris, Davis & Davis, 2003). Methods & Procedures Speech and language therapists (n = 15) from a range of clinical and geographical settings in the Republic of Ireland were invited to participate in one of four focus groups. Focus group discussions were facilitated by an SLT researcher and were audio-recorded and transcribed. Analysis was completed following Braun and Clarke’s six phases of thematic analysis (Braun and Clarke, 2006). Outcomes & Results Four key themes were identified; i. Infrastructure, Resources, and Support, ii. SLT beliefs, biases and influencers, iii. Function & Fit, and iv. ICT and Living Successfully with Aphasia. The SLTs discussed a wide range of factors that influence their decisions to introduce ICT in aphasia rehabilitation, which related to the person with aphasia, the SLT, the broad rehabilitation environment, and the ICT programme features. In addition, several barriers and facilitators associated with ICT-delivered aphasia rehabilitation were highlighted. Conclusion This research highlights a range of issues for SLTs in relation to the use of ICT in aphasia rehabilitation within an Irish context. The potential benefits of using ICT devices in rehabilitation and in functional everyday communication were discussed. However, SLTs also identified many barriers that prevent easy implementation of this mode of rehabilitation.

Expected Value of Sample Information to Guide the Design of Group Sequential Clinical Trials

Article

Full-text available

Dec 2021

Introduction: Adaptive designs allow changes to an ongoing trial based on prespecified early examinations of accrued data. Opportunities are potentially being missed to incorporate health economic considerations into the design of these studies. Methods: We describe how to estimate the expected value of sample information for group sequential design adaptive trials. We operationalize this approach in a hypothetical case study using data from a pilot trial. We report the expected value of sample information and expected net benefit of sampling results for 5 design options for the future full-scale trial including the fixed-sample-size design and the group sequential design using either the Pocock stopping rule or the O'Brien-Fleming stopping rule with 2 or 5 analyses. We considered 2 scenarios relating to 1) using the cost-effectiveness model with a traditional approach to the health economic analysis and 2) adjusting the cost-effectiveness analysis to incorporate the bias-adjusted maximum likelihood estimates of trial outcomes to account for the bias that can be generated in adaptive trials. Results: The case study demonstrated that the methods developed could be successfully applied in practice. The results showed that the O'Brien-Fleming stopping rule with 2 analyses was the most efficient design with the highest expected net benefit of sampling in the case study. Conclusions: Cost-effectiveness considerations are unavoidable in budget-constrained, publicly funded health care systems, and adaptive designs can provide an alternative to costly fixed-sample-size designs. We recommend that when planning a clinical trial, expected value of sample information methods be used to compare possible adaptive and nonadaptive trial designs, with appropriate adjustment, to help justify the choice of design characteristics and ensure the cost-effective use of research funding. Highlights: Opportunities are potentially being missed to incorporate health economic considerations into the design of adaptive clinical trials.Existing expected value of sample information analysis methods can be extended to compare possible group sequential and nonadaptive trial designs when planning a clinical trial.We recommend that adjusted analyses be presented to control for the potential impact of the adaptive designs and to maintain the accuracy of the calculations.This approach can help to justify the choice of design characteristics and ensure the cost-effective use of limited research funding.

Report for the EcoNomics of Adaptive Clinical Trials (ENACT) project : Application of a Bayesian Value-Based Sequential Model of a Clinical Trial to the CACTUS and HERO Case Studies (with Guidance Material for Clinical Trials Units)

Article

Nov 2021

Post-stroke aphasia rehabilitation using computer-based Arabic software program: a randomized controlled trial

Article

Full-text available

Dec 2021

Background Aphasia is considered an acquired communication disorder. Language intervention in aphasia enhances the patient outcomes. Recently, computer programs are developed for the treatment of aphasia. It is an effective and a low-cost therapy choice. The aim of the study was to assess the effectiveness of language therapy using a computer-based Arabic software program for rehabilitation of post-stroke Arabic-speaking aphasic patients in comparison to the conventional language therapy. We conducted a randomized controlled trial with blinded endpoint evaluation. The trial included 50 aphasic patients. They were randomized into either group I or group II to receive 48 therapy sessions using the Arabic software program (group I) or the conventional therapy (group II). The primary outcome was a measure of improvement in language abilities. It was measured using the Arabic version of the Boston Diagnostic Aphasia Examination to detect any significant improvement in the language of both groups in comparison to pre-therapy results. The post-therapy results of both groups were compared to each other to document the effectiveness of the software program. Results A total of 105 aphasic patients were screened and 50 subjects were randomized to the intervention groups [40 subjects were males, mean age of the patients: 57.04 years± SD 10.88 for group I and 58.80 years ± SD 11.58 for group II]. The therapy results showed a significant improvement from the baseline in both groups. There was no significant difference in the post-therapy results between group I and group II except for some items whereas group I showed more significant improvement. Conclusions Language therapy using a computer-based Arabic software program was as effective as the conventional therapy in the improvement of language abilities of Arabic-speaking aphasic patients.

Digital therapeutics in neurology

Article

Full-text available

Mar 2022
J NEUROL

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

Supporting wellbeing through peer-befriending (SUPERB) for people with aphasia: A feasibility randomised controlled trial

Article

Full-text available

Feb 2021

Objective To determine the feasibility and acceptability of peer-befriending, for people with aphasia. Design Single-blind, parallel-group feasibility randomised controlled trial comparing usual care to usual care + peer-befriending. Participants and setting People with aphasia post-stroke and low levels of distress, recruited from 5 NHS Hospitals and linked community services; their significant others; and 10 befrienders recruited from community. Intervention Six 1-hour peer-befriending visits over three months. Main measures Feasibility parameters included proportion eligible of those screened; proportion consented; missing data; consent and attrition rates. Acceptability was explored through qualitative interviews. Outcomes for participants and significant others were measured at baseline, 4- and 10-months; for peer-befrienders before training and after one/two cycles of befriending. Results Of 738 patients identified, 75 were eligible of 89 fully screened (84%), 62 consented (83% of eligible) and 56 randomised. Attrition was 16%. Adherence was high (93% attended ⩾2 sessions, 81% all six). The difference at 10 months on the GHQ-12 was 1.23 points on average lower/better in the intervention arm (95% CI 0.17, −2.63). There was an 88% decrease in the odds of GHQ-12 caseness (95% CI 0.01, 1.01). Fourty-eight significant others and 10 peer-befrienders took part. Procedures and outcome measures were acceptable. Serious adverse events were few ( n = 10, none for significant others and peer-befrienders) and unrelated. Conclusions SUPERB peer-befriending for people with aphasia post-stroke experiencing low levels of distress was feasible. There was preliminary evidence of benefit in terms of depression. Peer-befriending is a suitable intervention to explore further in a definitive trial. Clinical trial registration-URL: http://www.clinicaltrials.gov Unique identifier: NCT02947776 Subject terms: Translational research, mental health, rehabilitation, quality and outcomes, stroke

Marginal assessment of the cost and benefits of aphasia treatment: Evidence from community-based telerehabilitation treatment for aphasia

Article

Jan 2021

Introduction Few studies have reported information related to the cost-effectiveness of traditional face-to-face treatments for aphasia. The emergence and demand for telepractice approaches to aphasia treatment has resulted in an urgent need to understand the costs and cost-benefits of this approach. Methods Eighteen stroke survivors with aphasia completed community-based aphasia telerehabilitation treatment, utilizing the Language-Oriented Treatment (LOT) delivered via Webex videoconferencing program. Marginal benefits to treatment were calculated as the change in Western Aphasia Battery-Revised (WAB-R) score pre- and post-treatment and marginal cost of treatment was calculated as the relationship between change in WAB-R aphasia quotient (AQ) and the average cost per treatment. Controlling for demographic variables, Bayesian estimation evaluated the primary contributors to WAB-R change and assessed cost-effectiveness of treatment by aphasia type. Results Thirteen out of 18 participants experienced significant improvement in WAB-R AQ following telerehabilitation delivered therapy. Compared to anomic aphasia (reference group), those with conduction aphasia had relatively similar levels of improvement whereas those with Broca’s aphasia had smaller improvement. Those with global aphasia had the largest improvement. Each one-point of improvement cost between US$89 and US$864 for those who improved (mean = US$200) depending on aphasia type/severity. Discussion Individuals with severe aphasia may have the greatest gains per unit cost from treatment. Both improvement magnitude and the cost per unit of improvement were driven by aphasia type, severity and race. Economies of scale to aphasia treatment–cost may be minimized by treating a variety of types of aphasia at various levels of severity.

Accessible Creativity with a Comic Spin

Conference Paper

Full-text available

Oct 2020

An Exploratory Study on Supporting Persons with Aphasia in Pakistan: Challenges and Opportunities

Conference Paper

Full-text available

Oct 2020

Factors Associated With Adherence to Self-Managed Aphasia Therapy Practice on a Computer—A Mixed Methods Study Alongside a Randomized Controlled Trial

Article

Full-text available

Nov 2020

Background: Aphasia is a communication disorder often acquired after a stroke. Independent use of specialist aphasia software on a home computer is a form of asynchronous tele-rehabilitation that can provide increased opportunity for practice of rehabilitation exercises. This study aimed to explore the factors associated with adherence to self-managed aphasia computer therapy practice. Method: A mixed methods exploration of adherence was conducted alongside the Big CACTUS randomized controlled trial [ISRCTN: 68798818]. The trial evaluated the clinical effectiveness of self-managed aphasia computer therapy. This study reports secondary analysis of data from participants randomized to the computer therapy group to investigate whether any demographic, clinical or intervention variables were associated with adherence to therapy practice. A sub-sample of the same participants took part in qualitative interviews exploring the factors perceived to influence the amount of aphasia computer therapy practice undertaken. Interviews were analyzed thematically. A convergence-coding matrix was used to triangulate the two sets of findings. Results: Data from 85 participants randomized to the computer therapy group were included in the quantitative analyses. At a clinical level, a greater length of time post-stroke was associated with higher adherence to self-managed aphasia therapy practice on a computer. At an intervention level, length of computer therapy access and therapist time supporting the participant were associated with greater adherence to computer therapy practice. Interviews with 11 patients and 12 informal carers identified a multitude of factors perceived to influence engagement with tele-rehabilitation by people with aphasia. The factors grouped around three themes: capability to use the computer therapy, having the opportunity to practice (external influences and technological issues) and motivation (beliefs, goals and intentions vs. personality, emotions, habit and reinforcement). Triangulation demonstrated convergence for the finding that participants' practiced computer-based therapy exercises more when they received increased support from a speech and language therapist. Conclusion: Clinicians delivering asynchronous tele-rehabilitation involving self-management of aphasia therapy practice on a computer should consider the factors found to be associated with engagement when deciding which patients may be suited to this option, as well as how they can be supported to optimize the amount of practice they engage in.

Investigating a new tablet-based telerehabilitation app in patients with aphasia: A randomised, controlled, evaluator-blinded, multicentre trial protocol

Article

Full-text available

Dec 2020

Introduction Aphasia is a common language disorder acquired after stroke that reduces the quality of life of affected patients. The impairment is frequently accompanied by a deficit in cognitive functions. The state-of-the-art therapy is speech and language therapy but recent findings highlight positive effects of high-frequency therapy. Telerehabilitation has the potential to enable high-frequency therapy for patients at home. This study investigates the effects of high-frequency telerehabilitation speech and language therapy (teleSLT) on language functions in outpatients with aphasia compared with telerehabilitative cognitive training. We hypothesise that patients training with high-frequency teleSLT will show higher improvement in language functions and quality of life compared with patients with high-frequency tele-rehabilitative cognitive training (teleCT). Methods and analysis This study is a randomised controlled, evaluator-blinded multicentre superiority trial comparing the outcomes following either high-frequency teleSLT or teleCT. A total of 100 outpatients with aphasia will be recruited and assigned in a 1:1 ratio stratified by trial site and severity of impairment to one of two parallel groups. Both groups will train over a period of 4 weeks for 2 hours per day. Patients in the experimental condition will devote 80% of their training time to teleSLT and the remaining 20% (24 min/day) to teleCT, vice versa for patients in the control condition. The primary outcome measure is the understandability of verbal communication on the Amsterdam Nijmegen Everyday Language Test and secondary outcome measures are intelligibility of the verbal communication, impairment of receptive and expressive language functions, confrontation naming. Other outcomes measures are quality of life and acceptance (usability and subjective experience) of the teleSLT system. Ethics and dissemination This study is approved by the Ethics Committee Bern (ID 2016-01577). Results will be submitted to a peer-reviewed journal. Trial registration number NCT03228264 .

Neuropsychological Rehabilitation

Chapter

Aug 2020

Cognitive impairment after stroke is common and can significantly hinder recovery of function and return to functional activities and roles. With an aging population and a decline in mortality rate post-stroke, addressing cognitive impairments in stroke survivors is of critical importance. The umbrella term vascular cognitive impairment (VCI) encompasses the continuum of cognitive impairment of cerebrovascular origin, ranging from mild impairment (with no significant impact on functional abilities) to vascular dementia. Management of individuals with impairments in cognition, affect, or behavior varies depending on the severity of the deficits and the functional consequences. Review of the evidence for rehabilitation of individuals with focal cognitive deficits post-stroke is the focus of this chapter. In this chapter, we define cognitive function broadly as interacting modular mental systems either containing and/or acting on domain-specific knowledge representations (e.g., language, spatial function, calculations).

CreaTable Content and Tangible Interaction in Aphasia

Conference Paper

Full-text available

Apr 2020

Closing the Digital Divide in Speech, Language, and Cognitive Therapy: Cohort Study of the Factors Associated With Technology Usage for Rehabilitation

Article

Full-text available

Feb 2020
J MED INTERNET RES

Background: For stroke, traumatic brain injury (TBI), and other neurologic conditions associated with speech-language disorders, speech and language therapy is the standard of care for promoting recovery. However, barriers such as clinician time constraints and insurance reimbursement can inhibit a patient's ability to receive the support needed to optimize functional gain. Although digital rehabilitation has the potential to increase access to therapy by allowing patients to practice at home, the clinical and demographic characteristics that impact a patient's level of engagement with technology-based therapy are currently unknown. Objective: This study aimed to evaluate whether the level of engagement with digital therapy differs by various patient characteristics, including age, gender, diagnosis, time from disease onset, and geographic location (urban vs rural). Methods: Data for patients with stroke or TBI that initiated the use of Constant Therapy, a remotely delivered, cloud-based rehabilitation program for patients with speech-language disorders, were retrospectively analyzed. Only data from therapeutic sessions completed at home were included. The following three activity metrics were evaluated: (1) the number of active weeks of therapy, (2) the average number of active therapy days per week, and (3) the total number of therapeutic sessions completed during the first 20 weeks of program access. An active day or week was defined as having at least one completed therapeutic session. Separate multiple linear regression models were performed with each activity measure as the dependent variable and all available patient demographics as model covariates. Results: Data for 2850 patients with stroke or TBI were analyzed, with the average patient completing 8.6 weeks of therapy at a frequency of 1.5 days per week. Contrary to known barriers to technological adoption, older patients were more active during their first 20 weeks of program access, with those aged 51 to 70 years completing 5.01 more sessions than patients aged 50 years or younger (P=.04). Similarly, patients living in a rural area, who face greater barriers to clinic access, were more digitally engaged than their urban counterparts, with rural patients completing 11.54 more (P=.001) sessions during their first 20 weeks of access, after controlling for other model covariates. Conclusions: An evaluation of real-world data demonstrated that patients with stroke and TBI use digital therapy frequently for cognitive and language rehabilitation at home. Usage was higher in areas with limited access to clinical services and was unaffected by typical barriers to technological adoption, such as age. These findings will help guide the direction of future research in digital rehabilitation therapy, including the impact of demographics on recovery outcomes and the design of large, randomized controlled trials.

The effect of augmented speech-language therapy delivered by telerehabilitation on poststroke aphasia—a pilot randomized controlled trial

Article

Jan 2020

Objective Pilot a definitive randomized controlled trial of speech-language telerehabilitation in poststroke aphasia in addition to usual care with regard to recruitment, drop-outs, and language effects. Design Pilot single-blinded randomized controlled trial. Setting Telerehabilitation delivered from tertiary rehabilitation center to participants at their home or admitted to secondary rehabilitation centers. Subjects People with naming impairment due to aphasia following stroke. Intervention Sixty-two participants randomly allocated to 5 hours of speech and language telerehabilitation by videoconference per week over four consecutive weeks together with usual care or usual care alone. The telerehabilitation targeted functional, expressive language. Main measures Norwegian Basic Aphasia Assessment: naming (primary outcome), repetition, and auditory comprehension subtests; Verb and Sentence Test sentence production subtest and the Communicative Effectiveness Index at baseline, four weeks, and four months postrandomization. Data were analyzed by intention to treat. Results No significant between-group differences were seen in naming or auditory comprehension in the Norwegian Basic Aphasia Assessment at four weeks and four months post randomization. The telerehabilitation group ( n = 29) achieved a Norwegian Basic Aphasia Assessment repetition score of 8.9 points higher ( P = 0.026) and a Verb and Sentence Test score 3 points higher ( P = 0.002) than the control group ( n = 27) four months postrandomization. Communicative Effectiveness Index was not significantly different between groups, but increased significantly within both groups. No adverse events were reported. Conclusion Augmented telerehabilitation via videoconference may be a viable rehabilitation model for aphasia affecting language outcomes poststroke. A definitive trial with 230 participants is needed to confirm results.

The use of technology to facilitate written language production in people with aphasia. L'utilisation de la technologie pour faciliter la production écrite des persons aphasiques. Short review, Revue de Neuropsychologie.

Article

Aug 2019

Anna Caute

In an age when digital technology is becoming central to communication, writing is increasingly important, with messaging and emailing often replacing telephone calls [1]. As written communication shifts to the digital modality, technology poses both challenges and opportunities to people with aphasia. The cognitive and linguistic demands of using technology present potential barriers [2], but recent research has also explored the potential of technology to facilitate writing. This mini review will describe the evidence base for using technology to support written production in aphasia therapy. It will describe a variety of applications, designed to remediate the impairment and facilitate functional writing skills, along with compensatory approaches which aim to bypass impaired writing skills. It will explore the role of the speech and language therapist in selecting the most suitable technology for an individual's needs and in training people with aphasia to use the technology. In addition, it will discuss methods of assessing the technology proficiency and functional writing skills of people with aphasia, and the inherent challenges. Résumé À une époque où la technologie numérique occupe une place centrale dans la communication, l'écrit devient de plus en plus important, la messagerie et l'envoi de courriels remplaç ant souvent les appels téléphoniques [1]. À mesure que la communication écrite passe à la modalité numérique, la technologie constitue tout à la fois une source de défis et d'opportunités pour les per-sonnes aphasiques. Les exigences cognitives et linguistiques inhérentes à l'utilisation de la technologie présentent des obstacles possibles [2], mais des recherches récentes ont aussi exploré le potentiel que représente la technologie pour faciliter l'écriture. Cette mini-revue décrira les données disponibles concernant l'utilisation de la technologie visant à renforcer la production écrite dans la rééducation de l'aphasie. Elle présentera également une variété d'applications conç ues pour remédier aux déficiences, faciliter les compéten-ces d'écriture fonctionnelle, ainsi que des approches compensatoires visant à contourner les habiletés d'écriture déficientes. Elle explorera le rôle de l'orthophoniste/logopédiste dans la sélection des outils technologiques les plus appropriés aux besoins de la personne aphasique, ainsi que dans l'entrainement à leur maîtrise. Enfin, elle proposera une discussion des méthodes d'évaluation de la maîtrise de ces outils et des compétences écrites fonctionnelles auxquelles peuvent prétendre les personnes aphasiques sans occulter les défis inhérents à celles-ci.

Digital Therapeutics: Emerging New Therapy for Neurologic Deficits after Stroke

Article

Full-text available

Sep 2019

Digital therapeutics is an evidence-based intervention using high-quality software, with the sole purpose of treatment. As many healthcare systems are encountering high demands of quality outcomes, the need for digital therapeutics is gradually increasing in the clinical field. We conducted review of the implications of digital therapeutics in the treatment of neurological deficits for stroke patients. The implications of digital therapeutics have been discussed in four domains: cognition, speech and aphasia, motor, and vision. It was evident that different forms of digital therapeutics such as online platforms, virtual reality trainings, and iPad applications have been investigated in many trials to test its feasibility in clinical use. Although digital therapeutics may deliver high-quality solutions to healthcare services, the medicalization of digital therapeutics is accompanied with many limitations. Clinically validated digital therapeutics should be developed to prove its efficacy in stroke rehabilitation.

How Well Do We Use Our Technology? Examining iPad Navigation Skills in Individuals With Aphasia and Older Adults

Article

Sep 2019

Purpose Technology is increasingly being used in rehabilitation, yet exposure and comfort with technology varies across individuals, particularly among older adults. There are limited ways to evaluate comfort with technology or teach people how to use technological devices. The objective of the current study was to develop an iPad task battery and evaluate performance by individuals with aphasia and older adults, further examining whether participants could learn to improve performance with written, verbal, and visual instructions. Method Thirty-two participants completed this study (16 with poststroke aphasia and 16 older adult controls). Participants completed 3 phases of testing: (a) baseline evaluation of performance of an iPad task battery, (b) teaching and practice of unknown tasks, and (c) retention evaluation. Participants were scored on accuracy, speed, and efficiency in each phase. Results were evaluated as a function of demographic and cognitive–linguistic variables. Results Results demonstrate that variability arises in people's abilities to perform tasks on an iPad and that cognitive skills such as executive functions, planning, and visuospatial attention relate to baseline scores of performance. The majority of participants with aphasia showed evidence of retaining information learned in the teaching and practice phase; however, they showed a lower percentage of retained lessons relative to controls. Conclusions Findings support the hypothesis that technology abilities vary among individuals with and without aphasia. Evaluating technology ability and the ability to learn technology is an important component to consider when prescribing tablet-based therapies.

Progression criteria in trials with an internal pilot: an audit of publicly funded randomised controlled trials

Article

Full-text available

Aug 2019
TRIALS

Background: With millions of pounds spent annually on medical research in the UK, it is important that studies are spending funds wisely. Internal pilots offer the chance to stop a trial early if it becomes apparent that the study will not be able to recruit enough patients to show whether an intervention is clinically effective. This study aims to assess the use of internal pilots in individually randomised controlled trials funded by the Health Technology Assessment (HTA) programme and to summarise the progression criteria chosen in these trials. Methods: Studies were identified from reports of the HTA committees' funding decisions from 2012 to 2016. In total, 242 trials were identified of which 134 were eligible to be included in the audit. Protocols for the eligible studies were located on the NIHR Journals website, and if protocols were not available online then study managers were contacted to provide information. Results: Over two-thirds (72.4%) of studies said in their protocol that they would include an internal pilot phase for their study and 37.8% of studies without an internal pilot had done an external pilot study to assess the feasibility of the full study. A typical study with an internal pilot has a target sample size of 510 over 24 months and aims to recruit one-fifth of their total target sample size within the first one-third of their recruitment time. There has been an increase in studies adopting a three-tiered structure for their progression rules in recent years, with 61.5% (16/26) of studies using the system in 2016 compared to just 11.8% (2/17) in 2015. There was also a rise in the number of studies giving a target recruitment rate in their progression criteria: 42.3% (11/26) in 2016 compared to 35.3% (6/17) in 2015. Conclusions: Progression criteria for an internal pilot are usually well specified but targets vary widely. For the actual criteria, red/amber/green systems have increased in popularity in recent years. Trials should justify the targets they have set, especially where targets are low.

Predicting Outcomes of Language Rehabilitation:Prognostic Factors for Immediate and Long-Term Outcomes After Aphasia Therapy

Article

Feb 2023
J SPEECH LANG HEAR R

Background: Aphasia therapy is an effective approach to improve language function in chronic aphasia. However, it remains unclear what prognostic factors facilitate therapy response at the individual level. Here, we utilized data from the POLAR (Predicting Outcomes of Language Rehabilitation in Aphasia) trial to (a) determine therapy-induced change in confrontation naming and long-term maintenance of naming gains and (b) examine the extent to which aphasia severity, age, education, time postonset, and cognitive reserve predict naming gains at 1 week, 1 month, and 6 months posttherapy. Method: A total of 107 participants with chronic (≥ 12 months poststroke) aphasia underwent extensive case history, cognitive-linguistic testing, and a neuroimaging workup prior to receiving 6 weeks of impairment-based language therapy. Therapy-induced change in naming performance (measured as raw change on the 175-item Philadelphia Naming Test [PNT]) was assessed 1 week after therapy and at follow-up time points 1 month and 6 months after therapy completion. Change in naming performance over time was evaluated using paired t tests, and linear mixed-effects models were constructed to examine the association between prognostic factors and therapy outcomes. Results: Naming performance was improved by 5.9 PNT items (Cohen's d = 0.56, p < .001) 1 week after therapy and by 6.4 (d = 0.66, p < .001) and 7.5 (d = 0.65, p < .001) PNT items at 1 month and 6 months after therapy completion, respectively. Aphasia severity emerged as the strongest predictor of naming improvement recovery across time points; mild (ß = 5.85-9.02) and moderate (ß = 9.65-11.54) impairment predicted better recovery than severe (ß = 1.31-3.37) and very severe (ß = 0.20-0.32) aphasia. Age was an emergent prognostic factor for recovery 1 month (ß = -0.14) and 6 months (ß = -0.20) after therapy, and time postonset (ß = -0.05) was associated with retention of naming gains at 6 months posttherapy. Conclusions: These results suggest that therapy-induced naming improvement is predictable based on several easily measurable prognostic factors. Broadly speaking, these results suggest that prognostication procedures in aphasia therapy can be improved and indicate that personalization of therapy is a realistic goal in the near future. Supplemental material: https://doi.org/10.23641/asha.22141829.

Delivering script therapy for people with aphasia in EVA park: Two single case treatment studies

Article

Full-text available

Feb 2023

BACKGROUND: There are few applications of virtual reality (VR) in aphasia rehabilitation. EVA Park is an online VR platform developed with and for people with aphasia. Our research is testing its potential to host aphasia therapies. OBJECTIVE: Two case studies evaluated if delivery of Script Therapy in EVA Park is feasible and acceptable to participants, whether it improved production of trained scripts and promoted generalisation to untrained scripts, narrative speech and functional communication. METHODS: Two participants with aphasia received 20 hours of Script Therapy in EVA Park. Feasibility was assessed through session attendance, completion of practice and ratings of treatment fidelity. Acceptability was explored via post therapy interviews. The impact of therapy on script production, narrative production and functional communication was assessed through measures administered twice before therapy, immediately post therapy and at 5 weeks follow up. RESULTS: Participants attended at least 85% of sessions. Compliance with practice was good for one, but not the other. Fidelity ratings indicated that over 80% of core treatment components were fully present in recorded sessions. Participants expressed positive views about the intervention. Therapy significantly improved the production of words in trained scripts, with maintenance for one participant. Neither participant improved in the production of untrained scripts or personal narratives. One improved on the assessment of functional communication, but the margin of change was small. CONCLUSIONS: The study adds to the evidence that EVA Park can host a range of interventions and that this platform is acceptable to its intended user group.

“Just Not Together”: The Experience of Videoconferencing for People with Aphasia during the Covid-19 Pandemic

Conference Paper

Apr 2022

A Systematic Review of Adherence Strategies for Adult Populations in Speech-Language Pathology Treatment

Article

Mar 2022
AM J SPEECH-LANG PAT

Purpose: Speech-language pathologists (SLPs) often advise adult patients to complete at-home programs in order to improve outcomes. Despite this widespread practice, relatively little is known about treatment adherence. The purposes of this systematic review were to identify adherence strategies and adherence tracking methods used by adult populations that are commonly treated by SLPs (i.e., dysphagia, aphasia, traumatic brain injury, dysphonia, dysarthria), and to identify the efficacy of these strategies. Method: The systematic review was conducted in accordance with A Measurement Tool to Assess Systematic Reviews guidelines. A comprehensive literature search was performed in three databases (CINAHL, PubMed, and Web of Science). Results: Of the 679 articles found, 18 were selected for analysis. Two thirds of the included articles received the second highest rating on the 5-point JAMA Quality Rating Scheme. Interventions designed to alter treatment adherence included (most to least frequent) computer programs, portable devices/phone apps, alarm reminders, instructional DVDs, check-ins from a clinician/volunteer, and wearable device. Adherence reporting methods included (most to least frequent) self-report diaries, computer program/app-aided collection, wearable device, and clinician/volunteer observation. Of the articles that reported practice frequency, 58% found that adherence strategies improved practice frequency as compared to control. Of the articles that reported treatment outcomes, 66% found that adherence strategies were associated with improved treatment outcomes as compared to control. Conclusions: The paucity of publications reviewed suggests that treatment adherence is considerably understudied in speech-language pathology. A clearer understanding of how to improve the design of adherence strategies could yield highly valuable clinical outcomes. Supplemental material: https://doi.org/10.23641/asha.19393793.

“There are endless areas that they can use it for”: speech-language pathologist perspectives of technology support for aphasia self-management

Article

Feb 2022

Background: Aphasia is a debilitating acquired language disorder that often persists as a chronic condition. However, long-term support options are scarce, necessitating the consideration of alternative approaches. Chronic condition self-management approaches, which aim to build self-efficacy and empower people to take responsibility for the day-to-day management of their health condition, may benefit people with aphasia (PwA). Technology is widely used in chronic condition self-management and investigation is required to determine whether it could play a role in aphasia self-management. Objective: This study aimed to explore speech-language pathologist (SLP) perspectives on the potential use of technology to support aphasia self-management. Methods: A qualitative study was conducted with 15 SLPs using semi-structured interviews. Qualitative content analysis was applied to verbatim transcripts to identify codes, categories, and sub-themes which were developed into themes. Results: Three themes were identified: (1) technology supports holistic aphasia self-management by providing additional avenues for service delivery, overall communication, and learning opportunities thus enhancing independence and life participation; (2) SLP and communication partner (CP) assistance can support PwA to use technology for aphasia self-management; (3) considerations and potential barriers to PwA use of technology for aphasia self-management. Conclusions: Technology can support aphasia self-management by expanding service delivery options, allowing for increased frequency and intensity of therapy practise, and facilitating communication and participation. Personal, professional, and organizational barriers should be addressed in the development of technology-enabled aphasia self-management approaches. SLPs and CPs can offer PwA assistance with technology but may themselves need additional support. Solutions for identified barriers should be considered, such as providing training in the use of technology and implementing aphasia-friendly modifications.IMPLICATIONS FOR REHABILITATIONSelf-management approaches are being explored in the area of aphasia management as a means of offering a holistic, sustainable intervention option that meets the long-term needs of people with aphasia.A range of technology-based resources are currently used in chronic condition self-management and in aphasia therapy, and there are many possibilities for the use of technology in aphasia self-management approaches.Speech-language pathologists identified that technology could facilitate aphasia self-management by expanding service delivery options (e.g., real-time and asynchronous telepractice), enabling increased frequency and intensity of therapy through providing a means of independent practise, offering options for augmentative alternative communication, and enhancing life participation by supporting social communication and daily tasks.,Speech-language pathologists are interested in using technology for aphasia self-management; however, barriers related to organizational policies, individual experience and confidence using technology, and technology itself must be addressed.

Behavioral interventions for poststroke aphasia

Chapter

Jan 2022

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

État de l'art sur les applications dédiées à la rééducation de personnes aphasiques: State of The Art Review On Applications Dedicated To The Rehabilitation Of People With Aphasia

Conference Paper

Apr 2021

Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review–Based, Individual Participant Data Network Meta-Analysis

Article

Full-text available

Mar 2022

Background and Purpose Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia. Methods Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori–defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI). Results Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58–26.16] Western Aphasia Battery–Aphasia Quotient; 5.23 [1.51–8.95] Aachen Aphasia Test–Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3–5+ days/week), and comprehension (4–5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases. Conclusions Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42018110947.

COVID-19 and Aphasia

Article

Full-text available

Nov 2021
CURR NEUROL NEUROSCI

Anthony Pak-Hin Kong

Purpose of Review Aphasia is an acquired neurological language disorder after brain damages. Persons with aphasia (PWA) are more susceptible to behavioral and emotional implications due to inherent communication and/or cognitive difficulties. Currently, little is known regarding the impact of COVID-19 on PWA. Recent Findings There are now growing reports with evidence of neurological and dysexecutive syndromes subsequent to interference of brain functions in acute patients with COVID-19, leading to variable aphasia-like symptoms. COVID-19 affected chronic PWA more in terms of disrupted communication and daily routines, worsened psychosocial well-being, and difficulties getting aphasia services that adequately addressed their needs. Summary Acute versus chronic PWA were disproportionately affected by COVID-19. Recognizing, examining, and managing COVID-19-related neurological and behavioral problems in PWA is not straightforward. As we passed the 1-year mark and approaching the 2-year mark of the onset of COVID-19, more research is necessary to prioritize strategies for improving current evidence-based care and rehabilitation of aphasia.

The Possibilities of Smart Clothing in Adult Speech Therapy: Speech Therapists' Visions for the Future

Conference Paper

Aug 2021

Effectiveness of information and communications technology interventions for stroke survivors and their support people: a systematic review

Article

Apr 2021
DISABIL REHABIL

Purpose: To examine the effectiveness of self-directed, off-the-shelf information and communications technology (ICT)-based interventions in improving the quality of life, physical and psychosocial outcomes of community-dwelling stroke survivors and their support persons (SP). Methods: Medline, EMBASE, CINAHL and Cochrane databases were searched (2006-19th June 2020) for randomized controlled trials, controlled trials, controlled before and after studies, or interrupted time series studies that met the eligibility criteria. The quality of included studies was assessed. Interventions effectiveness was narratively synthesized, as was participant adherence and acceptability. Results: Seventeen studies were eligible. Three studies were rated as low risk of bias across all methodological review criteria. Nine studies reported on interventions delivered using self-directed computer programs, two studies utilized internet or web-based support programs and six studies used mobile phone interventions. Few studies reported on intervention acceptability or adherence. Those that did generally reported good acceptability, although adherence was variable. Fifteen studies reported significant positive effects for at least one outcome examined including stroke-specific outcomes, physical outcomes, behavioural outcomes and health service use. No studies found an effect for psychosocial wellbeing. Conclusion: ICT-based interventions are likely to provide benefit to stroke survivors and their SPs. However, there is a need for further robustly designed intervention studies that include larger sample sizes, longer follow-up, and outcomes for SPs.Implications for RehabilitationICT-based interventions with minimal clinician supervision are likely to provide some benefits to stroke survivors and their SPs.There is insufficient evidence to allow recommendations to rehabilitation professionals regarding the type, length and intensity of ICT-based interventions for specific targeted outcomes.Rehabilitation professionals should use professional judgement prior to recommending ICT-based interventions to stroke survivors and their SPs.

An Umbrella Review of Aphasia Intervention descriPtion In Research: the AsPIRE project

Article

Jan 2021

Background: Recent reviews conclude that aphasia intervention is effective. However, replication and implementation require detailed reporting of intervention is and a specification of participant profiles. To date, reviews concentrate more on efficacy than on intervention reporting quality. Aims : The aim of this project is to review the descriptions of aphasia interventions and participants appearing in recent systematic reviews of aphasia intervention effectiveness. The relationship between the quality of these descriptions and the robustness of research design is explored, and the replicability of aphasia interventions is evaluated. Methods and Procedures : The scope of our search was an analysis of the aphasia intervention studies included in the and EBRSR 2018 systematic reviews, and in the RCSLT 2014 literature synthesis. Intervention descriptions published separately from the intervention study (i.e. published online, in clinical tools, or a separate trial protocols) were not included. The criteria for inclusion were that participants had aphasia, the intervention involved language and/or communication, and included the following research designs: Randomised Controlled Trial (RCT), comparison or control, crossover design, case series. Exclusion criteria included non-SLT interventions, studies involving fewer than four participants, conference abstracts, studies not available in English. Studies were evaluated for completeness of intervention description using the TIDieR Checklist. Additionally, we rated the quality of patient and intervention description, with particular reference to replicability. Outcomes and Results: Ninety-three studies were included. Only 14 studies (15%) had >50 participants. Fifty-six studies (60%) did not select participants with a specific aphasia profile, and a further 10 studies only described participants as non-fluent. Across the studies, an average of eight (of 12) TIDieR checklist items were given but information on where, tailoring, modification and fidelity items was rarely available. Studies that evaluated general aphasia intervention approaches tended to use RCT designs, whereas more specific intervention studies were more likely to use case series designs. Conclusions: Group studies were generally under-powered and there was a paucity of research looking at specific aphasia interventions for specific aphasia profiles. There was a trade-off between the robustness of the design and the level of specificity of the intervention described. While the TIDieR framework is a useful guide to information which should be included in an intervention study, it is insufficiently sensitive for assessing replicability. We consider possible solutions to the challenges of making large-scale trials more useful for determining effective aphasia intervention.

Telerehabilitation services for stroke

Article

Jan 2020

Background: Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face or when added to usual care. Objectives: To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self-care and domestic life and improved mobility, balance, health-related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions. Search methods: We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists. Selection criteria: Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation. Data collection and analysis: Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings. Main results: We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post-hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post-stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke. Primary outcome: we found moderate-quality evidence that there was no difference in activities of daily living between people who received a post-hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) -0.00, 95% confidence interval (CI) -0.15 to 0.15)). We found low-quality evidence of no difference in effects on activities of daily living between telerehabilitation and in-person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI -0.43 to 0.48). Secondary outcomes: we found a low quality of evidence that there was no difference between telerehabilitation and in-person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI -0.30 to 0.46). Pooling of three studies with 569 participants showed moderate-quality evidence that there was no difference between those who received post-discharge support interventions and those who received usual care on health-related quality of life (SMD 0.03, 95% CI -0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate-quality evidence that there was no difference in depressive symptoms when comparing post-discharge tele-support programs with usual care (SMD -0.04, 95% CI -0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI -2.17 to 4.64, low-quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in-person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial-related adverse events were reported. Authors' conclusions: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb Deficits in Aphasia: Verb-in-Isolation Treatments

Article

Oct 2019

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

Can hi-tech Augmentative and Alternative Communication effectively support communication for people with aphasia?

Chapter

Full-text available

Oct 2019

Rating experience of ICT-delivered aphasia rehabilitation: co-design of a feedback questionnaire

Article

Aug 2019

Background: Speech and language therapy can provide beneficial outcomes in post-stroke aphasia rehabilitation, and intensity is a key component of a successful programme. Information and communication technologies (ICT) may offer an option for the provision of intensive rehabilitation but the views of those undertaking this mode of rehabilitation must be considered to ensure motivation and adherence with self-administered rehabilitation. There is no consensus measure for recording feedback from people with aphasia on user experience of ICT-delivered aphasia rehabilitation. This paper reports on the collaborative development of a feedback questionnaire with people with aphasia for people with aphasia. Aims: There are three research aims (i) to develop a questionnaire to facilitate feedback on ICT-delivered aphasia rehabilitation by collaboratively working with people with aphasia in the design process, (ii) to describe the development process and the co-design techniques employed, and (iii) to explore the experiences of co-designers in the development process. Methods & Procedures: Using public patient involvement (PPI) in health research, a co-design process was employed throughout 6 group workshops. Six people with aphasia (43 to 76 years of age) with a range of aphasia severities (Western Aphasia Battery Aphasia Quotient range 24.4–83) engaged in the co-design process. The final product, an online user feedback questionnaire, was developed. Individual exit interviews were carried out with the co-designers after the workshops, and a thematic analysis of the interview data was completed. Outcomes & Results: The final questionnaire provides an outcome measure that investigates: cognitive workload, satisfaction, programme functionality and ease of use, and the level of assistance required when engaging in ICT-delivered aphasia rehabilitation. It is presented as an online survey in an aphasia-accessible format. Following the co-design experience, four themes were identified within the exit interviews: Group Dynamics, Balance of Complexity of Tasks, Reflection on Abilities and Positive Experience. The co-design process provided opportunities for social interaction with other people with aphasia and allowed co-designers to reflect on their own abilities. The workshops were considered accessible and facilitated their engagement in the co-design process. The process was inclusive and the co-designers reported feeling comfortable about contributing in the workshops and this was also noted in their feedback in the individual exit interviews. Conclusion: People with aphasia can, and should, be included in all stages of the aphasia research process and especially in the development and design of evaluation measures for use by people with aphasia.

An Object and Action Naming Battery

Article

Full-text available

Jan 2000
J NEUROLINGUIST

Aphasia rehabilitation and the role of computer technology: Can we keep up with modern times?

Article

Full-text available

Feb 2011

Mieke WME Van de Sandt-Koenderman

Numerous computer applications have been developed specifically for aphasia rehabilitation. In this paper, the role of these computer programs is discussed in relation to three complementary treatment approaches in aphasia rehabilitation: disorder-oriented treatment, functional treatment, and participation-oriented treatment. Most of the programs available focus on disorder-oriented treatment and several studies have reported a beneficial effect on language skills. Nowadays, in the context of disorder-oriented treatment, these applications are indispensible to achieve an adequate treatment frequency of at least 2 hours per week. Computer applications aiming at functional and social participation goals are less well-developed. Several studies show that high-technology AAC can be used to support off-line communication. Moreover, it is reported that the AAC training has a positive effect on overall communicative functioning. In the near future, computer applications for interactive communicative training may become an important tool in aphasia rehabilitation. Theoretically, the internet offers excellent opportunities to improve social participation for people with aphasia, but reading and writing problems limit their access to the internet. So far, only a few initiatives have been reported to support and increase their access.

Rethinking aphasia therapy: A neuroscience perspective

Article

Full-text available

Feb 2011

Rosemary Varley

This article explores how consideration of acquired speech and language disorders from the perspective of neuroscience permits new insights into the content and design of therapy for people with aphasia. Key proposals are that aspects of current therapies often neglect the sensory-motor components of speech and language processing, and the interconnectivity of sensory-perceptual and motor systems. Furthermore, current therapy regimes are often administered at too low an intensity to stimulate neural reorganization. Neuroscientific perspectives on learning are explored and in particular the issues of associationist learning, learned misuse, mirror neurone systems, and procedural and errorless learning. The value of use of computer programs in administering high intensity therapy is outlined and it is proposed that aphasia therapies can be enhanced if clinicians adopt an explicit neuroscientific rationale for intervention.

Effectiveness of Virtual Reality Using Wii Gaming Technology in Stroke Rehabilitation A Pilot Randomized Clinical Trial and Proof of Principle

Article

Full-text available

Jul 2010
STROKE

Background and purpose: Hemiparesis resulting in functional limitation of an upper extremity is common among stroke survivors. Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery, limited evidence is available on the efficacy of virtual reality for stroke rehabilitation. Methods: In this pilot, randomized, single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months, we compared the feasibility, safety, and efficacy of virtual reality using the Nintendo Wii gaming system (VRWii) versus recreational therapy (playing cards, bingo, or "Jenga") among those receiving standard rehabilitation to evaluate arm motor improvement. The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with the Wolf Motor Function Test, Box and Block Test, and Stroke Impact Scale at 4 weeks after intervention. Results: Overall, 22 of 110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41 to 83) years. Two participants dropped out after a training session. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm. The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group (P=0.75). There were no serious adverse events in any group. Relative to the recreational therapy group, participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds (Wolf Motor Function Test, 7.4 seconds; 95% CI, -14.5, -0.2) after adjustment for age, baseline functional status (Wolf Motor Function Test), and stroke severity. Conclusions: VRWii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.

Aphasia therapy on a neuroscience basis

Article

Full-text available

Jul 2008

Background Brain research has documented that the cortical mechanisms for language and action are tightly interwoven and, concurrently, new approaches to language therapy in neurological patients are being developed that implement language training in the context of relevant linguistic and non-linguistic actions, therefore taking advantage of the mutual connections of language and action systems in the brain. A further well-known neuroscience principle is that learning at the neuronal level is driven by correlation; consequently, new approaches to language therapy emphasise massed practice in a short time, thus maximising therapy quantity and frequency and, therefore, correlation at the behavioural and neuronal levels. Learned non-use of unsuccessful actions plays a major role in the chronification of neurological deficits, and behavioural approaches to therapy have therefore employed shaping and other learning techniques to counteract such non-use. Aims Advances in theoretical and experimental neuroscience have important implications for clinical practice. We exemplify this in the domain of aphasia rehabilitation. Main Contribution Whereas classical wisdom had been that aphasia cannot be significantly improved at a chronic stage, we here review evidence that one type of intensive language-action therapy (ILAT)—constraint-induced aphasia therapy—led to significant improvement of language performance in patients with chronic aphasia. We discuss perspectives for further improving speech-language therapy, including drug treatment that may be particularly fruitful when applied in conjunction with behavioural treatment. In a final section we highlight intensive and rapid therapy studies in chronic aphasia as a unique tool for exploring the cortical reorganisation of language. Conclusions We conclude that intensive language action therapy is an efficient tool for improving language functions even at chronic stages of aphasia. Therapy studies using this technique can open new perspectives for research into the plasticity of human language circuits.

Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia

Article

Full-text available

Nov 2008

This systematic review summarizes evidence for intensity of treatment and constraint-induced language therapy (CILT) on measures of language impairment and communication activity/participation in individuals with stroke-induced aphasia. A systematic search of the aphasia literature using 15 electronic databases (e.g., PubMed, CINAHL) identified 10 studies meeting inclusion/exclusion criteria. A review panel evaluated studies for methodological quality. Studies were characterized by research stage (i.e., discovery, efficacy, effectiveness, cost-benefit/public policy research), and effect sizes (ESs) were calculated wherever possible. In chronic aphasia, studies provided modest evidence for more intensive treatment and the positive effects of CILT. In acute aphasia, 1 study evaluated high-intensity treatment positively; no studies examined CILT. Four studies reported discovery research, with quality scores ranging from 3 to 6 of 8 possible markers. Five treatment efficacy studies had quality scores ranging from 5 to 7 of 9 possible markers. One study of treatment effectiveness received a score of 4 of 8 possible markers. Although modest evidence exists for more intensive treatment and CILT for individuals with stroke-induced aphasia, the results of this review should be considered preliminary and, when making treatment decisions, should be used in conjunction with clinical expertise and the client's individual values.

Speech and language therapy: Does it work?

Article

Full-text available

Jul 1996

PROGRESSNeurogenesis in adult primate neocortex: an evaluation of the evidence

Article

Full-text available

Feb 2002
NAT REV NEUROSCI

Pasko Rakic

Reports of continuous genesis and turnover of neurons in the adult primate association neocortex--the site of the highest cognitive functions--have generated great excitement. Here, I review the available evidence, and question the scientific basis of this claim.

Self-Administered Cued Naming Therapy: A Single-Participant Investigation of a Computer-Based Therapy Program Replicated in Four Cases

Article

Full-text available

Dec 2007

This study examined the benefits of a self-administered, clinician-guided, computer-based, cued naming therapy. Results of intense and nonintense treatment schedules were compared. A single-participant design with multiple baselines across behaviors and varied treatment intensity for 2 trained lists was replicated over 4 participants. Two lists of words were treated sequentially. The same methods and equal numbers of treatment sessions were used, but the number of sessions per week differed across word lists: nonintense (2/week) or intense (5/week). Probes of performance on both word lists were carried out to examine acquisition, maintenance, and generalization. There was strong evidence of improved naming (acquisition) of trained words in 3 of the 4 participants regardless of treatment intensity. There was strong evidence of maintenance for 1 participant and moderate evidence for the remaining 3 participants. Evidence of generalization to untrained words was weak. Results suggest that self-administered, computer-based, cued naming therapy using a common mixed-cue protocol may be beneficial to a wide range of persons with aphasia regardless of treatment schedule. If results are replicated with a larger sample, treatments such as this may be a low-cost supplement or extension to traditional aphasia therapy.

Translational Research in Aphasia: From Neuroscience to Neurorehabilitation

Article

Full-text available

Mar 2008

In this article, the authors encapsulate discussions of the Language Work Group that took place as part of the Workshop in Plasticity/NeuroRehabilitation Research at the University of Florida in April 2005. In this narrative review, they define neuroplasticity and review studies that demonstrate neural changes associated with aphasia recovery and treatment. The authors then summarize basic science evidence from animals, human cognition, and computational neuroscience that is relevant to aphasia treatment research. They then turn to the aphasia treatment literature in which evidence exists to support several of the neuroscience principles. Despite the extant aphasia treatment literature, many questions remain regarding how neuroscience principles can be manipulated to maximize aphasia recovery and treatment. They propose a framework, incorporating some of these principles, that may serve as a potential roadmap for future investigations of aphasia treatment and recovery. In addition to translational investigations from basic to clinical science, the authors propose several areas in which translation can occur from clinical to basic science to contribute to the fundamental knowledge base of neurorehabilitation. This article is intended to reinvigorate interest in delineating the factors influencing successful recovery from aphasia through basic, translational, and clinical research.

The Comprehensive Aphasia Test

Book

Jan 2004

Treatment-induced neuroplasticity following intensive naming therapy in a case of chronic Wernicke's aphasia

Article

Jul 2010

Background: Renewed interest in the effects of intensity on treatment has led to development of short-term, intensive treatment protocols, such as Constraint-Induced Language Therapy (CILT), in which participants with chronic aphasia begin to show statistically significant language improvements in as little as 2 weeks. Given its relatively short treatment cycle, CILT is also a good choice of treatment methodology for studying brain/behaviour plasticity in post-stroke aphasia.Aims: This study aimed to examine differences between two short, intensive treatment protocols in a participant with chronic Wernicke's aphasia both in terms of treatment outcomes and changes in patterns of BOLD signal activation.Methods & Procedures: The participant (ACL) participated in language testing and an fMRI overt speech confrontation-naming paradigm pre and post 2 weeks of CILT, post 2 weeks of unconstrained language therapy (PACE), and 6 months post-CILT. He named 48 black/white line drawings from each of four conditions: treated (CILT or PACE), untreated, or consistently correctly named pictures.Outcomes & Results: Naming treated pictures improved, even in the scanner, while naming untreated pictures did not. About one third of PACE and three-fourths of CILT gains were maintained. Rather than a distinct pattern of activation distinguishing treated from untreated or CILT from PACE pictures, ACL recruited a frontal network during naming of all pictures that included left middle and inferior frontal cortex, SMA and pre-SMA, and that varied in spatial extent and degree of activation according to accuracy and performance expectation. In post-hoc analyses of accuracy, this frontal network was most active during incorrect trials. At 6 months post-CILT, compared to controls, incorrect naming recruited a large and significant bilateral network including right Wernicke's area homologue.Conclusions: Results suggest that short, intensive therapy can improve naming and jumpstart language recovery in chronic aphasia, whether responses are constrained to the speech modality or not. Modulation of a left frontal network was associated with accuracy in naming and may represent compensatory adaptation to improve response selection, self-monitoring, and/or inhibition.

Conversational script performance in adults with non‐fluent aphasia: Treatment intensity and aphasia severity

Article

Jul 2009

Background: A growing body of research in aphasia treatment has indicated that greater amount and intensity of treatment is associated with better outcomes in individuals with chronic aphasia. AphasiaScriptsis a computerised conversational script training program that simultaneously collects accurate, reliable data about amount and intensity of treatment.Aims: The purpose of this study was first to investigate the relationship between amount of treatment and improvement on conversational script performance in persons with chronic non‐fluent aphasia, and second to investigate the influence of severity of language impairment on this relationship.Methods & Procedures: We collected computer‐generated treatment data from 17 participants with chronic non‐fluent aphasia during the 9‐week AphasiaScripts treatment protocol. Participants practised three individualised conversational scripts for 3 weeks each. We computed two measures of outcome performance: percent change in script content (script‐related words) and percent change in rate (script‐related words per minute).Outcomes & Results: Amount of treatment varied greatly, from 1.9 to 16.9 hours per week. Amount of treatment was significantly correlated with percent change in script content (r = .67, p

Superhighway to promoting a client‐therapist partnership? Using the Internet to deliver word‐retrieval computer therapy, monitored remotely with minimal speech and language therapy input

Article

Mar 2004

Background: Advances in information and communications technology have not only made independent speech and language therapy practice using a computer possible, it is now feasible to monitor this therapy from a different location ( “remotely”). Aims: This paper describes an evaluation of whether therapy delivered this way is efficacious and acceptable in improving word‐retrieval and efficient in terms of therapist time. Methods & Procedures: Seven participants were recruited to a case series study, with an ABA design, where A represented a no‐treatment assessment phase. All were at least 2 years post CVA and had word‐finding difficulties associated with aphasia. Participants had access to therapy software on a home computer. Therapy exercises were updated remotely by a therapist from a clinic computer via the Internet. No face‐to‐face therapy took place. Outcomes & Results: Outcome measures included data on software usage, pre and post‐therapy language assessments, and pre and post‐therapy participant interviews to explore perceived benefits and user's views. Results showed intensive use of the system, and improvement in word retrieval skills. Conclusions: Results suggest this mode of therapy delivery is efficacious, acceptable, and gave participants a high degree of independence. Relatively little input in terms of therapist time is required. The findings are discussed in terms of implications for therapy delivery for people with aphasia.

A computer-implemented protocol for treatment of naming disorders: Evaluation of clinician-guided and partially self-guided instruction

Article

Oct 2002

Background: Computer-based rehabilitation programs are now available for patients' use at home and in the clinical setting, yet we have meagre outcome data associated with their usefulness under self- and/or clinician-guided conditions. Aims: We assess the benefits of a computer-delivered, hierarchical phonological cueing protocol (cued naming) under two conditions of instruction, (1) with full clinician guidance or (2) in partial independence. Methods & procedures: We employed a single-subject experimental design, which was replicated over six chronic aphasic subjects, three in each instruction condition. Subjects with deficits identified as primarily phonological in nature were administered a phonological treatment, utilising a computerised therapy program (MossTalk Words), under one of the two conditions. Outcomes & Results: Training-specific acquisition and maintenance was demonstrated in both conditions. Limited and variable generalisation patterns were noted. Conclusions: Chronic aphasic individuals with moderate-to-severe phonologically based naming impairment can benefit from a computerised cued-naming protocol and independent work on the computer can be an effective adjunct to clinician-guided therapy.

Computerized hierarchical reading treatment in aphasia

Article

Mar 1992

Computerized reading activities were presented to 43 chronic aphasic subjects who were no longer receiving speech-language therapy in an attempt to determine the effectiveness of computer-provided treatment. Subjects were randomly assigned to one of three conditions: 78-hours of Computer Reading Treatment, 78-hours of Computer Stimulation (‘non-language’ activities), or No Treatment. Clinician interaction was minimal. Treatment software automatically adjusted task difficulty in response to subject performance by incorporating traditional treatment procedures, such as heirarchically arranged tasks and measurement of performance on baseline and generalization stimulus sets, in conjunction with complex branching algorithms. Three administrations of standardized tests at baseline, three months and six months revealed improved scores (p < 0·05) for the Treatment group. Additionally, the Treatment group made more improvement (p < 0·05) on the Porch Index of Communicative Ability Overall score than the other two groups. No statistically significant differences in improvement were measured between the Stimulation and No Treatment groups. Results suggest that 1) computerized reading treatment can be administered with minimal assistance from a clinician, 2) improvement on the computerized treatment tasks generalizes to improvement on non-computer language performance, 3) improvement results from the specific language content of the software and not simply the stimulation provided by the computer, and 4) chronic aphasic patients can improve performance through computerized treatment.

On the Use of the Upper Confidence Limit for the Variance from a Pilot Sample for Sample Size Determination

Article

Jan 1996
BIOMETRICAL J

In a recent paper, Browne (1995) investigated the use of a pilot sample for sample size calculation. Monte Carlo simulations indicated that using a 100 · (1 — γ) per cent upper one-sided confidence limit on the population varíance σ2 leads to a sample size that guarantees the planned power with a probability of at least 1 − γ. The purpose of this paper is to get further insight into the results of Browne by analytical considerations. Furthermore, the expected power is investigated when applying the strategy and recommendations for the choice of the pilot sample size are given.

Designing clinical trials with uncertain estimates of variability

Article

Oct 2004
PHARM STAT

Steven A. Julious

An estimated sample size is a function of three components: the required power, the predetermined Type I error rate, and the specified effect size. For Normal data the standardized effect size is taken as the difference between two means divided by an estimate of the population standard deviation. However, in early phase trials one may not have a good estimate of the population variance as it is often based on the results of a few relatively small trials. The imprecision of this estimate should be taken into account in sample size calculations. When estimating a trial sample size this paper recommends that one should investigate the sensitivity of the trial to the assumptions made about the variance and consider being adaptive in one's trial design. Copyright © 2004 John Wiley & Sons Ltd.

Sample size of 12 per group rue of thumb for a pilot study

Article

Oct 2005
PHARM STAT

Steven A. Julious

When designing a clinical trial an appropriate justification for the sample size should be provided in the protocol. However, there are a number of settings when undertaking a pilot trial when there is no prior information to base a sample size on. For such pilot studies the recommendation is a sample size of 12 per group. The justifications for this sample size are based on rationale about feasibility; precision about the mean and variance; and regulatory considerations. The context of the justifications are that future studies will use the information from the pilot in their design. Copyright © 2005 John Wiley & Sons, Ltd.

Speech and Language Therapy for Aphasia Following Stroke

Article

May 2010

Background: Aphasia is an acquired language impairment following brain damage which affects some or all language modalities: expression and understanding of speech, reading and writing. Approximately one-third of people who have a stroke experience aphasia. Objectives: To assess the effectiveness of speech and language therapy (SLT) for aphasia following stroke. Search strategy: We searched the Cochrane Stroke Group Trials Register (last searched April 2009), MEDLINE (1966 to April 2009) and CINAHL (1982 to April 2009). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders, searched reference lists of relevant articles and contacted other researchers and authors. Selection criteria: Randomised controlled trials comparing SLT versus no SLT, SLT versus social support or stimulation, and one SLT intervention versus another SLT intervention. SLT refers to a formal speech and language therapy intervention that aims to improve language and communication abilities and in turn levels of communicative activity and participation. Social support and stimulation refers to an intervention which provides social support or communication stimulation but does not include targeted therapeutic interventions. Direct comparisons of different SLT interventions refers to SLT interventions that differ in terms of duration, intensity, frequency or method of intervention or in the theoretical basis for the SLT approach. Data collection and analysis: Two review authors independently extracted the data and assessed the quality of included trials. We sought missing data from study investigators if necessary. Main results: We included 30 trials (41 paired comparisons) in the review: 14 subcomparisons (1064 participants) compared SLT with no SLT; six subcomparisons (279 participants) compared SLT with social support and stimulation; and 21 subcomparisons (732 participants) compared two approaches to SLT. In general, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures. Authors' conclusions: This review shows some indication of the effectiveness of SLT for people with aphasia following stroke. We also observed a consistency in the direction of results which favoured intensive SLT over conventional SLT, though significantly more people withdrew from intensive SLT than conventional SLT. SLT facilitated by a therapist-trained and supervised volunteer appears to be as effective as the provision of SLT by a professional. There was insufficient evidence to draw any conclusions in relation to the effectiveness of one SLT approach over another.

Computers in the Treatment of Chronic Aphasia

Article

Feb 2010
Semin Speech Lang

Richard C. Katz

Computers and related technology can increase the amount of treatment received by adults with chronic aphasia. Computers used in treatment, however, are only valuable to the patient if the intervention is efficacious. Real and potential applications of computer technology are discussed in the context of three roles of computerized aphasia treatment for adults with chronic aphasia. Pertinent studies regarding Phases 1 and 2 are briefly described. The only Phase 3 study of efficacy of computerized aphasia treatment is more fully described and its implications discussed.

Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome

Article

Feb 2009

In a recent randomized trial, we were unable to confirm the previously reported high effectiveness of CCBT. Therefore, the aim of the current study was to have a closer look at usage and acceptability (i.e. expectancy, credibility, and satisfaction) of the intervention. Depressed participants (N=200) were given login codes for unsupported online CCBT. A track-and-trace system tracked which components were used. We used a 9-month follow-up period. Uptake was sufficient, but dropout was high. Many usage indices were positively associated with short-term depressive improvement, whereas only homework was related to long-term improvement. Acceptability was good and expectancy could predict long-term, but not short-term outcome. Associations between use of CCBT and improvement are merely correlational. Our sample was too depressed in relation to the scope of the intervention. We relied on online self-report measures. Analyses were exploratory in nature. Although CCBT might be a feasible and acceptable treatment for depression, means to improve treatment adherence are needed for moderately to severely depressed individuals.

The Efficacy of Computer-Provided Reading Treatment for Chronic Aphasic Adults

Article

Jul 1997

We examined the effects of computer-provided reading activities on language performance in chronic aphasic patients. Fifty-five aphasic adults were assigned randomly to one of three conditions: computer reading treatment, computer stimulation, or no treatment. Subjects in the computer groups used computer 3 hours each week for 26 weeks. Computer reading treatment software consisted of visual matching and reading comprehension tasks. Computer stimulation software consisted of nonverbal games and cognitive rehabilitation tasks. Language measures were administered to all subjects at entry and after 3 and 6 months. Significant improvement over the 26 weeks occurred on five language measures for the computer reading treatment group, on one language measure for the computer stimulation group, and on none of the language measures for the no-treatment group. The computer reading treatment group displayed significantly more improvement on the Porch Index of Communicative Ability "Overall" and "Verbal" modality percentiles and on the Western Aphasia Battery Aphasia "Quotient" and "Repetition" subtest than the other two groups. The results suggest that (a) computerized reading treatment can be administered with minimal assistance from a clinician, (b) improvement on the computerized reading treatment tasks generalized to non-computer language performance, (c) improvement resulted from the language content of the software and not stimulation provided by a computer, and (d) the computerized reading treatment we provided to chronic aphasic patients was efficacious.

Modelling Valuations for EuroQOL Health States

Article

Dec 1997
MED CARE

Paul Dolan

It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these. In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a "tariff" of EuroQol values from this data. A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level. The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.

A Meta-Analysis of Clinical Outcomes in the Treatment of Aphasia

Article

Mar 1998

Randall Robey

An extensive search of aphasia-treatment literature yielded 55 reports of clinical outcomes satisfying the essential criteria for inclusion in a meta-analysis. The results confirmed those of an earlier meta-analysis in demonstrating the utility of aphasia treatments, generally considered, for bringing about desirable clinical outcomes. Beyond the general case, the new findings address clinical utility in finer detail than was previously possible. Effects of treatment for aphasia are synthesized and assessed for each of four important dimensions: amount of treatment, type of treatment, severity of aphasia, and type of aphasia.

Constraint-Induced Therapy of Chronic Aphasia After Stroke

Article

Aug 2001
STROKE

Patients with chronic aphasia were assigned randomly to a group to receive either conventional aphasia therapy or constraint-induced (CI) aphasia therapy, a new therapeutic technique requiring intense practice over a relatively short period of consecutive days. CI aphasia therapy is realized in a communicative therapeutic environment constraining patients to practice systematically speech acts with which they have difficulty. Patients in both groups received the same amount of treatment (30 to 35 hours) as 10 days of massed-practice language exercises for the CI aphasia therapy group (3 hours per day minimum; 10 patients) or over a longer period of approximately 4 weeks for the conventional therapy group (7 patients). CI aphasia therapy led to significant and pronounced improvements on several standard clinical tests, on self-ratings, and on blinded-observer ratings of the patients' communicative effectiveness in everyday life. Patients who received the control intervention failed to achieve comparable improvements. Data suggest that the language skills of patients with chronic aphasia can be improved in a short period by use of an appropriate massed-practice technique that focuses on the patients' communicative needs.

Intensity of Aphasia Therapy, Impact on Recovery * Aphasia Therapy Works!

Article

Apr 2003
STROKE

It has been speculated that the conflicting results demonstrated across poststroke aphasia therapy studies might be related to differences in intensity of therapy provided across studies. The aim of this study is to investigate the relationship between intensity of aphasia therapy and aphasia recovery. A MEDLINE literature search was conducted to retrieve clinical trials investigating aphasia therapy after stroke. Changes in mean scores from each study were recorded. Intensity of therapy was recorded in terms of length of therapy, hours of therapy provided per week, and total hours of therapy provided. Pearson correlation was used to assess the relationship between changes in mean scores of outcome measures and intensity of therapy. Studies that demonstrated a significant treatment effect provided 8.8 hours of therapy per week for 11.2 weeks versus the negative studies that only provided approximately 2 hours per week for 22.9 weeks. On average, positive studies provided a total of 98.4 hours of therapy, whereas negative studies provided 43.6 hours of therapy. Total length of therapy time was found to be inversely correlated with hours of therapy provided per week (P=0.003) and total hours of therapy provided (P=0.001). Total length of therapy was significantly inversely correlated with mean change in Porch Index of Communicative Abilities (PICA) scores (P=0.0001). The number of hours of therapy provided in a week was significantly correlated to greater improvement on the PICA (P=0.001) and the Token Test (P=0.027). Total number of hours of therapy was significantly correlated with greater improvement on the PICA (P<0.001) and the Token Test (P<0.001). Intense therapy over a short amount of time can improve outcomes of speech and language therapy for stroke patients with aphasia.

Sample size redetermination for repeated measures studies

Article

Apr 2004

Steven Julious

Long-Term Stability of Improved Language Functions in Chronic Aphasia After Constraint-Induced Aphasia Therapy

Article

Aug 2005
STROKE

In response to the established notion that improvement of language functions in chronic aphasia only can be achieved through long-term treatment, we examined the efficacy of a short-term, intensive language training, constraint-induced aphasia therapy (CIAT). This program is founded on the learning principles of prevention of compensatory communication (constraint), massed practice, and shaping (induced). Twenty-seven patients with chronic aphasia received 30 hours of training over 10 days. Twelve patients were trained with the CIAT program. For 15 patients the training included a module of written language and an additional training in everyday communication, which involved the assistance of family members (CIATplus). Outcome measures included standardized neurolinguistic testing and ratings of the quality and the amount of daily communication. Language functions improved significantly after training for both groups and remained stable over a 6-month follow-up period. Single case analyses revealed statistically significant improvements in 85% of the patients. Patients and relatives of both groups rated the quality and amount of communication as improved after therapy. This increase was more pronounced for patients of the group CIATplus in the follow-up. Results confirm that a short-term intense language training, based on learning principles, can lead to substantial and lasting improvements in language functions in chronic aphasia. The use of family and friends in the training provides an additional valuable element. This effective intervention can be successfully used in the rehabilitation of chronic aphasia patients. Additionally, its short-term design makes it economically attractive for service providers.

One size does not fit all: obtaining informed consent from people with aphasia

Jan 2011
30

Palmer R

Palmer R., Paterson G. One size does not fit all: obtaining informed consent from people with aphasia. Adv Clin Neurosci Rehabil. 2011;11:30-31.

Guide to the Methods of Technology Appraisal. National Institute of Clinical Excellence Available at: www.nice.org.uk/media

Feb 2008

National Institute
Clinical Health
Excellence

National Institute for Health and Clinical Excellence. Guide to the Methods of Technology Appraisal. National Institute of Clinical Excellence; 2008. Available at: www.nice.org.uk/media/B52/A7/ TAMethodsGuide UpdatedJune2008.pdf. Accessed January 10, 2012.

Jan 2008
1282-1299

Реабилитация И Профилактика

ЛЕЧЕНИЕ, РЕАБИЛИТАЦИЯ И ПРОФИЛАКТИКА induced aphasia. J Speech Lang Hear Res. 2008;51:1282–1299.

Jan 2004

K Swinburn
G Porter
D Howard

Swinburn K., Porter G., Howard D. Comprehensive Aphasia Test. London, UK: Psychology Press; 2004.

K Swinburn
Porter
D Howard

Computer Therapy Compared With Usual Care for People With Long-Standing Aphasia Poststroke A Pilot Randomized Controlled Trial

Abstract

No full-text available