Pilot Results for ECoLoGiC-Tx: A New Conversation-Level Intervention Improving Language in People With Moderate to Severe Aphasia.

PURPOSE: This study reports pilot data for a novel intervention, ECoLoGiC-Tx, delivered to four people with moderate to severe aphasia. ECoLoGiC-Tx addresses language and communication in unstructured, participant-led conversation. The speech-language pathologist (SLP) uses a framework to choose turns that facilitate a social interaction. When communication breakdown occurs, the SLP implements a least-to-most hierarchy to maximize the people with aphasia's (PWA's) independence in self-repair. ECoLoGiC-Tx draws its theoretical underpinnings from conversation analysis and theories of rehabilitation, including principles of complexity, neuroplasticity, and learning. METHOD: Four PWA attended 60-min sessions twice weekly for 10 weeks. Assessment occurred at pretreatment, posttreatment, and 6-week maintenance. Outcomes included established discourse measures for conversation and monologue, tests of language and functional communication, and patient-/family-reported outcome measures (P/FROMs). Discourse samples were collected three times per assessment. Interrater reliability and fidelity for assessment and treatment procedures are reported. RESULTS: Participants presented with Broca's aphasia (one moderate, one severe) or conduction aphasia (one moderate, one severe). Each demonstrated improvements in discourse, test batteries, and P/FROMs. They all demonstrated reduced aphasia severity measured by the Western Aphasia Battery-Revised at posttreatment or maintenance. Change in conversation and monologue was robust for three participants, but was mixed for one person (P1: moderate Broca's aphasia). P/FROMs indicated improvement at posttreatment and maintenance for all participants. Most treatment gains were maintained at 6-week follow-up. CONCLUSIONS: This study provides promising results for ECoLoGiC-Tx to improve language function of people with chronic moderate to severe aphasia. Generalization occurred to tests, functional communication, spontaneous conversation, and structured monologue tasks.

Analyzing Language in the Picnic Scene Picture and in Conversation: The Type of Discourse Sample We Choose Influences Findings in People With Aphasia.

PURPOSE: People with aphasia express that improved conversational discourse is a primary rehabilitation goal. Discourse is usually assessed using monologue, such as a picture description task, but research shows that language in monologue varies from language in everyday conversation. Consequently, we investigated the relationship of language in unstructured conversation and in the picnic scene picture because it is a part of the most often used aphasia battery (Western Aphasia Battery-Revised) and thus is frequently used to inform therapy. Second, because previous research suggests people with severe aphasia may not demonstrate language production variability between types of monologue-level discourse, we evaluated the relationship of severity and the difference in scores between conversation and the picnic scene task. METHOD: Thirty-four people with mild-to-severe aphasia described the picnic scene and provided a conversation sample. We measured language production and communicative success using seven measures with established psychometrics in conversation/monologue. We conducted correlations to answer the research questions. RESULTS: Correlations were moderate and weaker for the measures in the two conditions. A strong negative relationship was demonstrated between aphasia severity and global coherence. All other relationships were moderate and weaker for the remaining measures when correlated with aphasia severity (also negative). CONCLUSIONS: Results are consistent with other studies indicating that language varies in different types of discourse. We conclude that for accurate, meaningful assessment, discourse sampling needs to include the specific type of discourse the individual wishes to address in therapy, because discourse samples and their findings are not interchangeable.

"If You Just Stay With Me and Wait You'll Get an Idea of What I'm Saying": The Communicative Benefits of Time for Conversational Self-Repair for People With Aphasia.

PURPOSE: This study investigated the communicative benefits of self-repair during conversation for persons with aphasia (PWAs). Self-repair of trouble sources is an interactional priority that emphasizes autonomy and competence. Of equal importance, conversationalists desire to minimize silences and work together to ensure forward movement (progressivity) of conversation. Simultaneously achieving progressivity and self-repair is challenging in aphasia, and PWAs and their partners often make trade-off decisions between these two activities. Conversation-level aphasia interventions usually focus on supportive techniques that promote participation while maintaining progressivity, effectively favoring progressivity over self-repair. This study evaluates the benefits of an alternative approach that shifts the emphasis to self-repair, thereby highlighting potential trade-off costs of routinely forgoing self-repair to achieve progressivity. METHOD: Ten people with mild-to-moderate aphasia each held two conversations with two different partners. When trouble sources characterized by silent and/or filled pauses occurred, partners maintained a supportive and engaged stance, allowing PWAs time to self-repair. We analyzed language produced during these "edited turns" using three paradigms considering form, content, and use. RESULTS: The data yielded 311 edited turns. For form, on average, each edited turn resulted in 3.72 words; for content, most edited turns contained autobiographical information; for use, approximately 40% of edited turns introduced new information, and 40% added to the ongoing topic. The remainder were either ambiguous or comments such as, "I can't think of it." CONCLUSIONS: When given engaged support and time to self-repair, PWAs contributed meaningful personal information to conversations for approximately 80% of edited turns. Importantly, self-repair often resulted in self-expression that directed the conversation, which is a communicative role critical for empowering agency and identity. This research opens a dialogue about benefits and limitations of approaches that prioritize either progressivity or self-repair and how to balance the two to optimize therapeutic benefits for each individual. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19379738.

Toward Empowering Conversational Agency in Aphasia: Understanding Mechanisms of Topic Initiation in People With and Without Aphasia.

PURPOSE: This study examined topic initiation (TI) in conversations involving people with aphasia (PWA), matched people without aphasia (M-PWoA), and speech-language pathologists who were their conversation partners (SLP-Ps). For each speaker type, we analyzed patterns of distribution of typical mechanisms of TI and patterns of simultaneous use of multiple TI mechanisms. Lastly, we examined associations between use of simultaneous TI mechanisms and communicative success. METHOD: Twenty PWA and 20 M-PWoA each participated in two conversations with SLP-Ps. Conversation samples were analyzed for TI locations and mechanisms, with results tallied for each speaker type following a published typology. A measure of communicative success was applied to TI utterances. Rank-order correlations were conducted to evaluate the patterns of distribution of the TI mechanisms between speaker types and the patterns of multiple mechanism usage between speaker types. Descriptive analysis was conducted to provide additional insight to the TI behaviors of each speaker type and to evaluate the relationship between multiple TI mechanisms and communicative success. RESULTS: All speaker types used cohesion most often to achieve TI. PWA used an abrupt method of TI (noncoherent TI) more often than other speaker types. A single mechanism of TI was used most often by all speaker types, except for SLP-Ps when they were in conversations with PWA. In this case, SLP-Ps most often used two or more layered mechanisms of TI. SLP-Ps also used a highly salient TI mechanism with greater frequency when speaking with PWA than observed between other speaker types. When PWA layered mechanisms of TI, they appeared to be more likely to achieve better communicative success. CONCLUSIONS: Specific, teachable behaviors such as favoring certain TI mechanisms and using multiple TI mechanisms may improve communicative success during TI for PWA. Furthermore, findings suggest that SLP-Ps modify their TI behaviors when speaking to PWA. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.17699423.

Assessing Language in Unstructured Conversation in People With Aphasia: Methods, Psychometric Integrity, Normative Data, and Comparison to a Structured Narrative Task.

Purpose This study evaluated interrater reliability (IRR) and test-retest stability (TRTS) of seven linguistic measures (percent correct information units, relevance, subject-verb-[object], complete utterance, grammaticality, referential cohesion, global coherence), and communicative success in unstructured conversation and in a story narrative monologue (SNM) in persons with aphasia (PWAs) and matched participants without aphasia (M-PWoAs). Furthermore, the relationship of language in unstructured conversation and SNM was investigated for these measures. Methods Twenty PWAs and 20 M-PWoAs participated in two unstructured conversations on different days with different speech-language pathologists trained as social conversation partners. An 8- to 12-min segment of each conversation was analyzed. Additionally, a wordless picture book was used to elicit an SNM sample at each visit. Correlational analyses were conducted to address the primary research questions. Normative range and minimal detectable change data were also calculated for the measures in both conditions. Results IRR and TRTS were moderate to good for parametric measures and moderate to excellent for nonparametric measures for both groups, except for TRTS for referential cohesion for the PWAs in conversation. Furthermore, in PWAs, a strong correlation was demonstrated for three of eight measures across conditions. Moderate or weaker correlations were demonstrated for three of eight measures, and correlations for two of eight measures were not significant. An ancillary finding was no significant differences occurred for sample-to-sample variability between the two conditions for any measure. Conclusions This study replicates previous research demonstrating the feasibility to reliably measure language in unstructured conversation in PWAs. Furthermore, this study provides preliminary evidence that language production varies for some measures between unstructured conversation and SNM, contributing to a literature base that demonstrates language variation between different types of monologue. Thus, these findings suggest that inclusion of the specific types of discourse of interest to the PWA may be important for comprehensive assessment of aphasia. Supplemental Material https://doi.org/10.23641/asha.16569360.

Experiences of Social Distancing During Coronavirus Disease 2019 as a Catalyst for Changing Long-Term Care Culture.

Purpose In this article, we draw a parallel between the experience of social isolation that occurred throughout the world during the Coronavirus Disease 2019 pandemic and similar experiences occurring in everyday life for people with communication disorders living in long-term care (LTC) facilities. We propose that speech-language pathologists can use the widespread experience of social isolation as a learning catalyst in the effort to shift the LTC culture to one that more highly values a communicative environment that is accessible to all, thereby reducing risk of social isolation for those with communication disorders. Conclusions Many training paradigms for promoting an accessible communicative environment are available in the speech-language pathology literature, yet institutional barriers exist for their widespread implementation. Overcoming these barriers is a challenge that requires awareness and learning on the part of staff and administration regarding the impact of an unfriendly communicative environment on social isolation, and the resulting psychosocial consequences. Learning theory indicates that new learning in adults is motivated by connections between personal experiences and the material to be learned. Explicitly infusing established training programs with the experience of social isolation brought on by the Coronavirus Disease 2019 pandemic may be the key needed for changing the communicative environment in LTC.

Measuring Global Coherence in People With Aphasia During Unstructured Conversation.

Purpose Global coherence is an essential macrolinguistic discourse skill that speakers use to formulate discourse to convey meaning with maintenance to a topic. When global coherence is poor, the listener's ability to understand how the discourse makes sense as a whole is diminished. Measures exist to evaluate global coherence in people with aphasia during monologue tasks (e.g., picture description). The aim of the current research is to develop such a measure for unstructured conversation and to explore how global coherence is impacted by aphasia during conversation. A global coherence measure for conversation is required because markedly different cognitive and linguistic demands are made for production of different types of discourse. Thus, a structured monologue measure cannot be used with validity for unstructured conversation. To adequately evaluate global coherence during conversation, a measure specific to the demands of conversation is required. Method We adapted the 4-point Global Coherence Scale (Wright & Capilouto, 2012; Wright et al., 2013), a monologue-level measure of global coherence to conversation, resulting in the 4-point Global Coherence Scale in unstructured conversation (GCSconv). We conducted statistical evaluation of the reliability/stability of the 4-point GCSconv in 18 unstructured conversations held by nine people with aphasia. Utterances with low global coherence scores were classified following a recent methodology to describe how breakdown in these utterances contributed to diminished global coherence (Hazamy & Obermeyer, 2019). Results The 4-point GCSconv demonstrated excellent inter/intrarater reliability and test-retest stability. Nonspecific language and off-topic comments contributed most frequently to lowered global coherence. Conclusions Findings suggest the 4-point GCSconv may be a feasible and reliable measure of global coherence in conversation. This measure adds to a core of emerging reliable discourse measures for conversation. As such, it has potential to inform assessment and treatment of everyday conversation and to investigate the relationship of global coherence in structured monologue and unstructured conversation. Supplemental Material https://doi.org/10.23641/asha.12469187.

Evaluating Change in the Conversation of a Person With Mild Aphasia After Attentive Reading With Constrained Summarization-Written Treatment.

Purpose The purpose of this project was to evaluate the effect of a discourse-level treatment, Attentive Reading with Constrained Summarization-Written (ARCS-W), on conversational discourse. ARCS-W aims to improve spoken and written output by addressing the cognitive-linguistic requirements of discourse production through constrained summarization of novel material. Method This is an experimentally controlled case study with a single participant, Bill. Three conversation samples were collected at pretreatment, and a single conversation was collected 1 month after treatment. The participant completed 24 ARCS-W treatment sessions, and each session included reading and then summarizing a novel current event article following specific constraints (use lexically precise words, stay on topic, use complete sentences) in speaking and writing. Conversation outcomes evaluated the success of each utterance (1-4 scale), grammaticality, and the proportion of utterances with relevant content (relevant utterances). Additionally, behavioral manifestations of word-finding difficulty were evaluated in conversation. Results Bill improved communicative success at the utterance level based on the minimal detectable change. He also demonstrated reductions in behavioral manifestations of lexical retrieval difficulty based on decreases in the percentage of false starts (e.g., t*, t*), mazes (e.g., uh, s*, um), and abandoned utterances. Bill did not increase the proportion of relevant utterances or grammatical utterances in conversation. Conclusions This case study provides preliminary evidence of the potential impact of ARCS-W treatment in conversation. Additionally, the measures implemented to evaluate conversation represent a promising adaptation of a novel methodology to capture change in conversation. Supplemental Material https://doi.org/10.23641/asha.12375053.

"By the Way" How People With Aphasia and Their Communication Partners Initiate New Topics of Conversation.

Purpose The ability to initiate new topics of conversation is a basic skill integral to communicative independence and agency that is susceptible to breakdown in aphasia (Barnes, Candlin, & Ferguson, 2013), yet this discourse skill has received little research attention. Healthy adults (HAs) follow 3 established patterns of structural organization to cue the conversation partner when an utterance is intended to initiate a new topic (Schegloff & Sacks, 1973; Svennevig, 1999). In addition, speakers have the option to use these mechanisms of topic initiation (TI) individually or in conjunction with one another. Occasionally, speakers do not follow these conversational macrostructure expectations, in which case TI occurs abruptly, referred to as a noncoherent TI (NC-TI; Mentis & Prutting, 1991). Understanding how TI is disrupted by aphasia requires foundational knowledge regarding the relative use/combined use of TI mechanisms and NC-TI in HAs and persons with aphasia (PWAs). The purpose of this study is to investigate how PWAs and their conversation partners initiate new topics of conversation and to determine the relationship between the number of TI methods used and communicative success (CS) in persons with mild aphasia (PWA-Mild) and persons with moderate and severe aphasia (PWA-Mod/Sev). Method Six PWA-Mild and 4 PWA-Mod/Sev engaged in 15-min unstructured conversations with different HA partners. Utterances were coded for types of TI used by both partners and were evaluated for CS using a 4-point scale (Leaman & Edmonds, 2019) for PWAs. Results/Implications PWAs used NC-TI with a much greater frequency than HAs who never used NC-TI. The rate of NC-TI was associated with increased severity of aphasia. HAs and PWA-Mild used cohesion most often as the method for TI, while PWA-Mod/Sev used it least often. CS was moderately positively correlated with the number of methods of TI used in PWA-Mod/Sev. However, no such correlation existed for PWA-Mild; this group achieved a high degree of CS on TI utterances, independent of the number of methods of TI used. Findings include the clinical implication suggesting PWA-Mod/Sev may benefit from simultaneous use of TI mechanisms to achieve better CS during conversation. Supplemental Material https://doi.org/10.23641/asha.9765164.

Revisiting the Correct Information Unit: Measuring Informativeness in Unstructured Conversations in People With Aphasia.

Purpose The purpose of this study was to determine whether the correct information unit (CIU) can be reliably applied to unstructured conversational discourse in people with aphasia (PWA). The CIU was developed by Nicholas and Brookshire (1993) to measure word-level informativeness in structured monologue-level discourse and is widely used by clinicians and researchers for this purpose. A case study (Oelschlaeger & Thorne, 1999) investigating the use of the CIU in conversation has suggested potential issues with interrater reliability (IRR), which has discouraged application of the CIU to this discourse context. However, no further research has been conducted to replicate or extend this finding. Given a clinical and research need for reliable linguistic measures appropriate for use in unstructured conversation, revisiting the reliability, stability, and suitability of the CIU is indicated. Method The CIU protocol developed by Nicholas and Brookshire (1993) was modified according to the needs of conversational discourse, resulting in the CIU in conversation (CIUconv) protocol. Two speech-language pathology graduate student research assistants completed training on use of the CIUconv with the 1st author. Sixteen conversations held by 8 PWA (i.e., 2 conversations each) were used as language samples to determine IRR of percent CIU (%CIU) in conversation through use of the CIUconv. Test-retest stability of %CIU as applied per this protocol was then assessed across the 2 conversations collected for each PWA. Results Use of the CIUconv resulted in excellent IRR of %CIU for each research assistant and the 1st author. Likewise, test-retest stability for the measure was excellent. Results were evaluated at both the group and individual levels. Conclusions %CIU demonstrated excellent interrater and test-retest reliability when applied to unstructured conversation using the CIUconv procedure, which was developed to account for expected linguistic characteristics of conversation. These findings suggest that %CIU may be a feasible, reliable measure of informativeness in unstructured conversation in PWA when the CIUconv is used by trained raters.

Conversation in Aphasia Across Communication Partners: Exploring Stability of Microlinguistic Measures and Communicative Success.

Purpose The aim of this study was to determine if people with aphasia demonstrate differences in microlinguistic skills and communicative success in unstructured, nontherapeutic conversations with a home communication partner (Home-P) as compared to a speech-language pathologist communication partner (SLP-P). Method Eight persons with aphasia participated in 2 unstructured, nontherapeutic 15-minute conversations, 1 each with an unfamiliar SLP-P and a Home-P. Utterance-level analysis evaluated communicative success. Two narrow measures of lexical relevance and sentence frame were used to evaluate independent clauses. Two broad lexical and morphosyntactic measures were used to evaluate elliptical and dependent clauses and to evaluate independent clauses for errors beyond lexical relevance and sentence frame (such as phonological and morphosyntactic errors). Utterances were further evaluated for presence of behaviors indicating lexical retrieval difficulty (pauses, repetitions, and false starts) and for referential cohesion. Results No statistical differences occurred for communicative success or for any of the microlinguistic measures between the SLP-P and Home-P conversation conditions. Four measures (2 of lexical retrieval and 1 each of communicative success and grammaticality) showed high correlations across the 2 conversation samples. Individuals showed variation of no more than 10 percentage points between the 2 conversation conditions for 46 of 56 data points. Variation greater than 10 percentage points tended to occur for the measure of referential cohesion and primarily for 1 participant. Conclusions Preliminary findings suggest that these microlinguistic measures and communicative success have potential for reliable comparison across Home-P and SLP-P conversations, with the possible exception of referential cohesion. However, further research is needed with a larger, more diverse sample. These findings suggest future assessment and treatment implications for clinical and research needs. Supplemental Material https://doi.org/10.23641/asha.7616312.