The Feasibility and Benefits of a Virtual Yoga Practice for Stroke Survivors With Aphasia.

PURPOSE: The purpose of this study was to (a) examine the feasibility of a virtual, adapted, aphasia-friendly yoga program for people with aphasia; (b) evaluate evidence of improvement in patient-reported outcomes and word retrieval; (c) explore the immediate impact of a yoga session on participant subjective emotional state; and (d) assess participant motivation and perceived benefits of participating in a yoga program. METHOD: This feasibility study employed a mixed-method design to document the feasibility of a virtual, 8-week adapted yoga program. A pre-/posttreatment design was used to assess patient-reported outcome measures for resilience, stress, sleep, and pain, as well as word-finding abilities. Semistructured interviews with participants were thematically analyzed to provide insight into participants' motivation and perceptions regarding their experience. RESULTS: Comparisons of pre- and postprogram group means suggest that participation in an 8-week adapted yoga program may positively impact perceptions of resilience (large effect), stress (medium effect), sleep disturbance (medium effect), and pain (small effect) for people with aphasia. Findings from within-session reports and brief, semistructured interviews with participants indicated positive outcomes and subjective experiences and suggest that people with aphasia are motivated to participate in yoga for a variety of reasons. CONCLUSIONS: This study is an important first step in confirming the feasibility of an adapted, aphasia-friendly yoga program offered via a remote platform for people with aphasia. The findings support recent work suggesting that yoga may be a potent adjunct to traditional rehabilitation efforts to improve resilience and psychosocial aspects in persons with aphasia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22688125.

Identifying an Appropriate Picture Stimulus for a Bangla Picture Description Task.

PURPOSE: The absence of culture- and language-specific aphasia assessment in Bangla underscores a critical problem in communication sciences and disorders. Aphasia occurs in ~41% of Bangla-speaking stroke survivors. In the past 40 years, stroke incidence has doubled in low- and middle-income countries, such as Bangladesh and India, where there are ~250 million native Bangla speakers. This study aims to initiate the first step toward identifying an appropriate picture stimulus for the Bangla picture description task (PDT) intended for inclusion in a Bangla aphasia assessment. Researchers have reported the importance of cultural relevance and three visuographic variables of a picture (high-context, color, and photograph vs. black-and-white line drawing) for faster comprehension and comprehensive language production in people with aphasia and neurologically healthy adults. METHOD: Ninety-six neurologically healthy native Bangla speakers of three age groups (young 19-30, middle age 40-55, and older 65-89 years) were recruited to compare spontaneous language production for four selected culturally related and nonrelated picture stimuli with and without the three visuographic variables. Five linguistic variables were used to analyze the language samples. RESULTS: The results demonstrated a significant (a) picture type effect for moving-average type-token ratio, words per minute (WPM), and mean length of utterance in morphemes (MLU) and (b) age group effect for WPM, MLU, and complexity index. CONCLUSIONS: This study suggests that a culturally related high-context color photograph is the optimal choice for the Bangla PDT. This study also indicates reduced fluency, grammatical complexity, and syntactic complexity in healthy Bangla-speaking adults aged 65 years and above. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22233664.

AAC apps for aphasia: a pilot study on the role of intuition and learning.

PURPOSE: To characterize the untrained performance of people with aphasia (PWA) in finding symbols (single words) on two symbol-based augmentative and alternative communication applications (AAC apps). METHODS: Nine individuals with aphasia and no previous experience with AAC searched for five symbols on two grid display apps with differing representation systems and vocabulary (Proloquo2Go and Speak for Yourself) following a brief demonstration. Participants were allowed two minutes to locate each symbol on each app (Trial 1), following which the process was repeated with the same symbols (Trial 2) for both apps. Measured variables included total number of symbols found as well as average efficiency score, search time per symbol, and number of cell selections per second for successful trials. Participants were interviewed about their stated app preferences. RESULTS: In the absence of training, participants performed significantly better using Proloquo2Go for average search time (p < .001), and rate of cell selection (p < .001). No significant differences were found across trials. Seven of the nine participants expressed a preference for Proloquo2Go. CONCLUSIONS: Participant performance and stated preferences appeared to favour the layout found in Proloquo2Go, possibly suggestive of greater intuitiveness in the absence of training. However, significant learning was not observed across two trials, suggesting the importance of training and increased exposure.Implications for RehabilitationIndividuals who are diagnosed with aphasia may have long-term communication difficulties that require alternative means of communication.There are numerous commercially available augmentative and alternative communication applications (AAC apps) which may be beneficial for this population. However, there is limited research examining their usefulness.This study with a small sample of individuals with aphasia found that in the absence of training some apps may be easier to use than others.Additionally, the study found that learning may not occur in the absence of training highlighting the importance of treatment.

Are People With Poststroke Aphasia Receptive to Transcranial Direct Current Stimulation? A Survey.

PURPOSE: The objective of this study was to explore receptiveness of people with poststroke aphasia to receiving transcranial direct current stimulation (tDCS), including preferences for the treatment setting and schedule of tDCS delivery. METHOD: An online survey was distributed via e-mail, flyers, social media, and online newsletters to reach people with aphasia. Fisher's exact test examined the relationship of self-reported tDCS receptiveness to demographic, clinical, and other factors. RESULTS: Fifty-seven surveys were returned, and 50 complete surveys were analyzed. Twenty-eight percent of respondents had previously heard of tDCS. Sixty-six percent reported they would receive tDCS if it could help their aphasia, and only 6% reported that they definitely would not. There were statistically significant relationships between being receptive to tDCS and (a) not currently working, (b) being receptive to speech-language therapy, and (c) greater acceptance of potential temporary risks associated with tDCS. Most individuals (73%) who would consider tDCS were equivalently open to receiving it in the clinic or at home, yet the majority (64%) were open to more frequent sessions at home than in the clinic. Most respondents indicated that they would consider having tDCS "forever if it helped" (clinic: 51%; home: 68%). CONCLUSIONS: This is the first study to query individuals with aphasia about their receptiveness to tDCS outside the context of an intervention study. Responses suggest that a large majority of people with poststroke aphasia might be open to receiving tDCS if it can ameliorate their aphasia. Limitations include the small sample size, which does not adequately represent the broader population of people with aphasia, and that the survey did not provide the level of tDCS education crucial to inform shared decision making and person-centered care. However, future work may benefit from considering the practical implications of research designs (e.g., high intensity treatment outside the home) that may not, in application, be widely acceptable to primary stakeholders. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19611777.

Finding "Zen" in Aphasia: The Benefits of Yoga as Described by Key Stakeholders.

PURPOSE: Recently, the literature has witnessed a surging interest regarding the use of mind-body approaches with people who have aphasia, generating a plethora of possible outcome measures. During this same time, a core outcome set for aphasia has been recommended. The purpose of this clinical focus article is to give our survivor, co-survivor, and clinician stakeholder coauthors a platform to share their personal narrative regarding their yoga journey, with the goal of identifying primary outcome domains central to capturing the impact of yoga on the recovery process for people with poststroke aphasia. Ultimately, we hope this clinical focus article helps clinicians understand how yoga might benefit their patients and draws attention to potential outcome measures, while also highlighting the important fact that traditional aphasia assessments do not capture the improvements stakeholders pinpoint as crucial to the essence of mind-body interventions. METHOD: This clinical focus article summarizes the case reports of Terri's and Chase's poststroke yoga journeys using the power of personal narrative and an adapted photovoice method. Additional stakeholders share in this storytelling process, using a variety of narrative tools. As this story is unveiled, several patient-identified outcome domains are highlighted as essential to document the impact of yoga on survivors. RESULTS: Terri's and Chase's yoga journeys revealed the multifaceted impact of yoga on five domains: (a) feelings of wholeness and "zen," (b) increased attentional capacity for language tasks, (c) increased verbal fluency, (d) decreased pain, and (e) relationship mutuality. CONCLUSION: Team Yoga realized that the practice of yoga-whether as a stand-alone practice or integrated into therapy sessions-fosters feelings of wholeness or "zen," which likely correlates with decreased pain with a simultaneous increase in resilience and flexibility of coping strategies to manage the host of chronic poststroke challenges. Supplemental Material https://doi.org/10.23641/asha.17003464.

Identifiable Patterns of Trait, State, and Experience in Chronic Stroke Recovery.

BACKGROUND: Considerable evidence indicates that the functional connectome of the healthy human brain is highly stable, analogous to a fingerprint. OBJECTIVE: We investigated the stability of functional connectivity across tasks and sessions in a cohort of individuals with chronic stroke using a supervised machine learning approach. METHODS: Twelve individuals with chronic stroke underwent functional magnetic resonance imaging (fMRI) seven times over 18 weeks. The middle 6 weeks consisted of intensive aphasia therapy. We collected fMRI data during rest and performance of 2 tasks. We calculated functional connectivity metrics for each imaging run, then applied a support vector machine to classify data on the basis of participant, task, and time point (pre- or posttherapy). Permutation testing established statistical significance. RESULTS: Whole brain functional connectivity matrices could be classified at levels significantly greater than chance on the basis of participant (87.1% accuracy; P < .0001), task (68.1% accuracy; P = .002), and time point (72.1% accuracy; P = .015). All significant effects were reproduced using only the contralesional right hemisphere; the left hemisphere revealed significant effects for participant and task, but not time point. Resting state data could also be used to classify task-based data according to subject (66.0%; P < .0001). While the strongest posttherapy changes occurred among regions outside putative language networks, connections with traditional language-associated regions were significantly more positively correlated with behavioral outcome measures, and other regions had more negative correlations and intrahemispheric connections. CONCLUSIONS: Findings suggest the profound importance of considering interindividual variability when interpreting mechanisms of recovery in studies of functional connectivity in stroke.

A Review of Biological Interventions in Chronic Aphasia.

Aphasia is a common and debilitating condition following stroke. While the gold standard for aphasia treatment is behavioral speech-language therapy, benefits remain modest in chronic stages of recovery. This limitation motivates the pursuit of novel interventions for chronic aphasia. Here, we review biological approaches that have been used (or proposed for use, in the case of regenerative and genetic therapies) to treat chronic aphasia. These techniques aim to ameliorate the deficits of aphasia by directly manipulating brain function, rather than training lost or compensatory functions, although many have been used to augment effects of behavioral therapy. Specifically, we explore the most robust designs of transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and pharmacotherapy that have been applied in chronic (≥6 months) post-stroke aphasia. We also consider less investigated approaches including epidural cortical stimulation and photobiomodulation. All methods are currently in nascent phases and restricted to experimental studies and clinical trials. Although the evidence base remains limited, such interventions may ultimately improve language function and quality of life for those living with chronic aphasia. However, it is crucial that application of these methods consider the effects of concomitant speech-language therapy, as biological interventions combined with behaviorally induced experience-dependent plasticity will likely yield the most beneficial and durable outcomes.

Clinical Feasibility of Combining Transcranial Direct Current Stimulation with Standard Aphasia Therapy.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a safe, portable, and inexpensive form of noninvasive brain stimulation that appears to augment the effects of concurrent therapy. However, several methodological issues in existing studies distance tDCS from current clinical practice. In this study, we offered (and administered) tDCS to individuals seeking typical behavioral aphasia therapy on an outpatient basis. METHODS: We approached clients (n = 10) planning to receive standard aphasia therapy at a university clinic. Following a brief description of tDCS, we offered to provide stimulation during their therapy. Those interested and without contraindications participated in a double-blind, sham-controlled crossover study of tDCS paired with speech-language therapy provided twice weekly. Participants received active (2 mA) or sham tDCS during two eight-week therapy phases (separated by ten weeks) with the anode over Broca's area and the cathode on the contralateral forehead. Stimulation was provided for the first 20 minutes of each one-hour session. Prior to and following each phase, participants were video recorded telling the Cinderella narrative. Recordings were transcribed and analyzed for correct information units (CIUs). RESULTS: Seven individuals (70%) were interested in and eligible for tDCS. Data from four participants who completed the study indicated a large effect size favoring active over sham tDCS (Cohen's d = 1.32). The participant with the most severe deficits did not benefit from therapy in either condition. CONCLUSION: There is potential for tDCS to enhance meaningful communication outcomes in standard clinical practice. Further investigation is needed to replicate findings and determine individual characteristics predictive of treatment response.

Behavioral and neurological effects of tDCS on speech motor recovery: A single-subject intervention study.

This paper reports a feasibility study designed to evaluate the behavioral and neurological effects of using transcranial direct current stimulation (tDCS) in conjunction with speech motor learning treatment for individuals with acquired speech impairment subsequent to stroke. Most of the research using tDCS to enhance treatment outcomes in stroke recovery has focused on either limb motor control or aphasia treatment. Using a multiple-baseline multiple-probe crossover design, we compared both behavioral and brain connectivity-based outcomes following speech motor learning treatment with both Active tDCS and Sham tDCS. We observed that both treatment phases led to improvement in short-term maintenance, but that Active tDCS was associated with greater long-term maintenance improvement. Active tDCS was also associated with an increase in functional connectivity in the left hemisphere and interhemispherically in an ROI-based network analysis examining correlations among areas associated with speech production and acquired speech impairment. This report supports the possibility that tDCS may enhance both behavioral and neurological outcomes and indicates the importance of additional work in this area, although replication is required to confirm the extent and consistency of tDCS benefits on speech motor learning treatment outcomes.

Clinical Assessment of Characteristics of Apraxia of Speech in Primary Progressive Aphasia.

Purpose We sought to examine interrater reliability in clinical assessment of apraxia of speech (AOS) in individuals with primary progressive aphasia and to identify speech characteristics predictive of AOS diagnosis. Method Fifty-two individuals with primary progressive aphasia were recorded performing a variety of speech tasks. These recordings were viewed by 2 experienced speech-language pathologists, who independently rated them on the presence and severity of AOS as well as 14 associated speech characteristics. We calculated interrater reliability (percent agreement and Cohen's kappa) for these ratings. For each rater, we used stepwise regression to identify speech characteristics significantly predictive of AOS diagnosis. We used the overlap between raters to create a more parsimonious model, which we evaluated with multiple linear regression. Results Results yielded high agreement on the presence (90%) and severity of AOS (weighted Cohen's κ = .834) but lower agreement for specific speech characteristics (weighted Cohen's κ ranging from .036 to .582). Stepwise regression identified 2 speech characteristics predictive of AOS diagnosis for both raters (articulatory groping and increased errors with increased length/complexity). These alone accounted for ≥ 50% of the variance of AOS severity in the constrained model. Conclusions Our study adds to a growing body of research that highlights the difficulty in objective clinical characterization of AOS and perceptual characterization of speech features. It further supports the need for consensus diagnostic criteria with standardized testing tools and for the identification and validation of objective markers of AOS. Additionally, these findings underscore the need for a training protocol if diagnostic tools are to be effective when shared beyond the research teams that develop and test them and disseminated to practicing speech-language pathologists, in order to ensure consistent application.

Limb Apraxia: a Disorder of Learned Skilled Movement.

PURPOSE OF REVIEW: This chapter focuses on limb apraxia, a cognitive-motor disorder of learned skilled movement, and the nature of the spatiotemporal errors that disrupt movement sequences. RECENT FINDINGS: A cognitive model that attempts to reconcile conceptual and preparatory aspects of the motor program with perceptual and kinematic features will be discussed. An update on the localization of the praxis network will be provided. In addition, a long-held view that limb apraxia does not have ecological relevance will be disputed in the context of studies that have shown that limb apraxia (i) is one of the most important predictors of increased caregiver burden and (ii) is associated with impaired activities of daily living in post-stroke patients. This review summarizes current screening tools and the few randomized clinical controlled treatment studies to date. Limb apraxia is underdiagnosed and very few therapeutic options are available. Cognitive process models should be used to inform future controlled multi-modal treatment strategies.

Therapy-Induced Plasticity in Chronic Aphasia Is Associated with Behavioral Improvement and Time Since Stroke.

Cortical reorganization after stroke is thought to underlie functional improvement. Patterns of reorganization may differ depending on the amount of time since the stroke or the degree of improvement. We investigated these issues in a study of brain connectivity changes with aphasia therapy. Twelve individuals with chronic aphasia participated in a 6-week trial of imitation-based speech therapy. We assessed improvement on a repetition test and analyzed effective connectivity during functional magnetic resonance imaging of a speech observation task before and after therapy. Using structural equation modeling, patient networks were compared with a model derived from healthy controls performing the same task. Independent of the amount of time since the stroke, patients demonstrating behavioral improvement had networks that reorganized to be more similar to controls in two functional pathways in the left hemisphere. Independent of behavioral improvement, patients with remote infarcts (2-7 years poststroke; n = 5) also reorganized to more closely resemble controls in one of these pathways. Patients with far removed injury (>10 years poststroke; n = 3) did not show behavioral improvement and, despite similarities to the normative model and overall network heterogeneity, reorganized to be less similar to controls following therapy in a distinct right-lateralized pathway. Behavioral improvement following aphasia therapy was associated with connectivity more closely approximating that of healthy controls. Individuals who had a stroke more than a decade before testing also showed plasticity, with a few pathways becoming less like controls, possibly representing compensation. Better understanding of these mechanisms may help direct targeted brain stimulation.

Changes in dynamic resting state network connectivity following aphasia therapy.

Resting state magnetic resonance imaging (rsfMRI) permits observation of intrinsic neural networks produced by task-independent correlations in low frequency brain activity. Various resting state networks have been described, with each thought to reflect common engagement in some shared function. There has been limited investigation of the plasticity in these network relationships after stroke or induced by therapy. Twelve individuals with language disorders after stroke (aphasia) were imaged at multiple time points before (baseline) and after an imitation-based aphasia therapy. Language assessment using a narrative production task was performed at the same time points. Group independent component analysis (ICA) was performed on the rsfMRI data to identify resting state networks. A sliding window approach was then applied to assess the dynamic nature of the correlations among these networks. Network correlations during each 30-second window were used to cluster the data into ten states for each window at each time point for each subject. Correlation was performed between changes in time spent in each state and therapeutic gains on the narrative task. The amount of time spent in a single one of the (ten overall) dynamic states was positively associated with behavioral improvement on the narrative task at the 6-week post-therapy maintenance interval, when compared with either baseline or assessment immediately following therapy. This particular state was characterized by minimal correlation among the task-independent resting state networks. Increased functional independence and segregation of resting state networks underlies improvement on a narrative production task following imitation-based aphasia treatment. This has important clinical implications for the targeting of noninvasive brain stimulation in post-stroke remediation.

Imitation-based aphasia therapy increases narrative content: a case series.

OBJECTIVE: To test the generalization of an intensive imitation-based aphasia therapy to an unrelated narrative production task. DESIGN: ABA design study (A= no treatment; B= treatment) comparing imitation therapy to a baseline condition (pre-therapy). Participants produced narratives at two pre-therapy and two post-therapy time points. Narratives were analyzed for correct information units to determine the number and percent of communicative words produced. SETTING: A rehabilitation clinic and participants' homes. PARTICIPANTS: Nineteen people with chronic aphasia following left hemisphere stroke. INTERVENTIONS: Six weeks of intensive imitation therapy (3 x 30 minutes/day; 6 days/week) of words and phrases delivered via dedicated laptop. MAIN MEASURES: We performed t-tests to assess post-therapy changes in narrative production, as well as for intervals during which no intervention was provided. We used stepwise regression to examine the predictive value of demographic, behavioral, and neurological variables in determining treatment outcome. RESULTS: Significant gains were made on the narrative production task in both the number (mean = 34.36; p = 0.009) and percent (mean = 3.99; p = 0.023) of correct information units produced. For percent of correct information units, the number of therapy sessions completed was the sole predictor of changes in production following therapy (r= +0.542; p = 0.020). No variables predicted change in number of correct information units produced. There were no significant differences between the two pre-therapy or the two post-therapy time points ( p > 0.294). CONCLUSIONS: Intensive imitation-based aphasia therapy may promote generalization to an unrelated narrative production task. Further investigation is indicated.

Increased Modularity of Resting State Networks Supports Improved Narrative Production in Aphasia Recovery.

The networks that emerge in the analysis of resting state functional magnetic resonance imaging (rsfMRI) data are believed to reflect the intrinsic organization of the brain. One key property of such complex biological networks is modularity, a measure of community structure. This topological characteristic changes in neurological disease and recovery. Nineteen subjects with language disorders after stroke (aphasia) underwent neuroimaging and behavioral assessment at multiple time points before (baseline) and after an imitation-based therapy. Language was assessed with a narrative production task. Group independent component analysis was performed on the rsfMRI data to identify resting state networks (RSNs). For each participant and each rsfMRI acquisition, we constructed a graph comprising all RSNs. We assigned nodal community based on a region's RSN membership, calculated the modularity score, and then correlated changes in modularity and therapeutic gains on the narrative task. We repeated this comparison controlling for pretherapy performance and using a community structure not based on RSN membership. Increased RSN modularity was positively correlated with improvement on the narrative task immediately post-therapy. This finding remained significant when controlling for pretherapy performance. There were no significant findings for network modularity and behavior when nodal community was assigned without consideration of RSN membership. We interpret these findings as support for the adaptive role of network segregation in behavioral improvement in aphasia therapy. This has important clinical implications for the targeting of noninvasive brain stimulation in poststroke remediation and suggests potential for further insight into the processes underlying such changes through computational modeling.

Performance Variability as a Predictor of Response to Aphasia Treatment.

BACKGROUND: Performance variability in individuals with aphasia is typically regarded as a nuisance factor complicating assessment and treatment. OBJECTIVE: We present the alternative hypothesis that intraindividual variability represents a fundamental characteristic of an individual's functioning and an important biomarker for therapeutic selection and prognosis. METHODS: A total of 19 individuals with chronic aphasia participated in a 6-week trial of imitation-based speech therapy. We assessed improvement both on overall language functioning and repetition ability. Furthermore, we determined which pretreatment variables best predicted improvement on the repetition test. RESULTS: Significant gains were made on the Western Aphasia Battery-Revised (WAB) Aphasia Quotient, Cortical Quotient, and 2 subtests as well as on a separate repetition test. Using stepwise regression, we found that pretreatment intraindividual variability was the only predictor of improvement in performance on the repetition test, with greater pretreatment variability predicting greater improvement. Furthermore, the degree of reduction in this variability over the course of treatment was positively correlated with the degree of improvement. CONCLUSIONS: Intraindividual variability may be indicative of potential for improvement on a given task, with more uniform performance suggesting functioning at or near peak potential.