Effectiveness of Transcranial Direct Current Stimulation as an Adjuvant to Aphasia Treatment Following Stroke: Evidence From Systematic Reviews and Meta-Analyses.

PURPOSE: Transcranial direct current stimulation (tDCS) is a neuromodulation tool to amplify neural excitability and enhance outcomes associated with speech-language therapy (SLT). Stimulation currents to the left and right hemispheres vary in applying anodal (excitatory), cathodal (inhibitory), or bihemispheric signals. Several systematic reviews (SRs) and meta-analyses (MAs) have summarized the large literature examining tDCS for aphasia rehabilitation. The purpose of this project was to appraise the quality of SRs and MAs of tDCS for aphasia and examine the weight of the evidence for language outcomes in individuals with aphasia beyond SLT alone. METHOD: We searched four databases for SRs/MAs examining effects of tDCS for poststroke aphasia. We identified 16 reviews, with nine that incorporated MA to quantify results. Two reviewers reliably coded articles for methodological rigor using the AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews, Version 2). We then summarized findings of the 16 reviews. RESULTS: The AMSTAR 2 appraisal criteria suggest that critical weaknesses were noted among all reviews except those by Elsner et al. (2015, 2019). Reviews summarized three to 48 studies, as some included only randomized crossover trials and others included all trial designs. All SRs and one MA reported improvements following tDCS stimulation for general aphasia abilities and measures of repetition and speech fluency. Five recent MAs reported significant naming improvements following tDCS using all stimulation arrays. No tDCS effects were noted for comprehension measures. CONCLUSIONS: As the tDCS literature matured, the conclusions of MAs merged with earlier SRs reporting statistically positive benefits over SLT alone. Most consistent results are reported for naming measures, leaving some to question the clinical significance of tDCS effects for functional measures of aphasia recovery. Although the tDCS literature is expansive, important questions remain before the technique can be confidently recommended for clinical practice.

Effectiveness of Constraint-Induced Language Therapy for Aphasia: Evidence From Systematic Reviews and Meta-Analyses.

PURPOSE: Constraint-induced language therapy (CILT) is an aphasia treatment that incorporates neuroplasticity principles of forced verbal use and high-intensity training to facilitate language recovery in individuals with stroke-induced aphasia (Pulvermüller et al., 2001). The burgeoning CILT literature has led to systematic reviews (SRs) that summarize treatment results. In this project, we appraised the quality and examined findings reported in several SRs to draw conclusions about the effectiveness of CILT. METHOD: We searched multiple databases for SRs that summarized CILT research for poststroke aphasia. We identified six SRs, among which three summarized findings qualitatively and three included meta-analysis (MA) to quantify results. We rated each SR for methodologic quality using the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2; Shea et al., 2017) and extracted findings across the six SRs. RESULTS: Two reviewers reliably applied the AMSTAR 2 to the six SRs. Although the six SRs generally were conducted with satisfactory rigor, each was lacking two or more critical domains. Descriptive summaries in SRs reported positive effects of CILT for language and communication measures. However, the three MAs showed that effects of CILT often did not surpass those of comparison treatments for naming, comprehension, and repetition measures. MA findings were positive in a review that included all research designs and evaluated treatment effects for trained naming items. Generalized CILT effects for standardized language measures were limited in two other MAs. CONCLUSIONS: CILT led to improvements in a variety of language and communication measures. When compared with intensive multimodality treatments, CILT effects were similar, suggesting that training intensity may be the potent factor in CILT outcomes. Future SRs should be implemented with increased rigor across quality rating scale domains to increase confidence in conclusions.

Conversation as an Outcome of Aphasia Treatment: A Systematic Scoping Review.

PURPOSE: Conversation-focused speech-language pathology services are a top priority for people living with aphasia, but little is known about how researchers measure conversation as an outcome of treatment. This scoping review was undertaken to systematically review the evidence regarding the measurement of conversation in aphasia studies and to identify current practices and existing gaps. METHOD: A systematic literature search was conducted for studies published between January 1995 and September 2019 in multiple electronic databases. Covidence software was used to manage search results, study selection, and data charting processes. Data were extracted from each study and then collated and organized to elucidate the breadth of approaches, tools, or procedures oriented to measuring conversation as an outcome and identify gaps in the existing literature. RESULTS: The systematic search of the literature resulted in 1,244 studies. A total of 64 studies met inclusion criteria and were included in the review. The review summarizes the various tools and procedures used to measure conversation as an outcome of aphasia intervention, including variations in data collection and analysis procedures. The review also evaluates the quality of conversation measures in terms of psychometric properties and informal measures of validity. There was a total of 211 measures used across the 64 studies. CONCLUSIONS: While there was no clear measure that was objectively superior, several measures show promise and warrant future exploration. Some of the orientations, conceptualizations, and procedures we have presented can be seen as options that might be included in a future conversation-focused core outcome set. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21514062.

Applying Appraisal Tools in Aphasia Systematic Reviews: A Tutorial.

PURPOSE: A systematic review (SR) represents a rigorous process of identifying and summarizing current research to answer specific clinical questions. Not all SRs present high-quality information, because they do not adhere to established standards of conduct or reporting. This tutorial aims to (a) describe two tools developed in epidemiology for reporting (PRISMA 2020; Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and appraising (AMSTAR 2; A MeaSurement Tool to Assess Systematic Reviews) SRs and (b) exemplify the use of AMSTAR 2. First, we describe the intents of PRISMA 2020 and AMSTAR 2 and compare the items on each checklist. Next, we apply the AMSTAR 2 list of domains to critically appraise methodological quality in two randomly selected SRs, which describe aphasia treatment. Appraisal results are reported, including the AMSTAR 2 ratings for overall confidence in the results of each review. For each SR, the overall rating was critically low, indicating that within the seven critical domains of AMSTAR 2, the SR had more than one critical weakness. CONCLUSIONS: While PRISMA 2020 is a tool to guide preparation of SRs, to examine SR quality, the AMSTAR 2 is the tool of choice. Applied to two current aphasia treatment SRs, the AMSTAR 2 demonstrates that although both SRs were thorough, thoughtful summaries of a body of aphasia treatment literature, they did not achieve high ratings for methodological quality. Clinicians reading SRs are advised to familiarize themselves with quality assessment tools to assure that an SR meets expected criteria to document internal and external validity of the SR process, so resulting findings can be confidently applied for patients with aphasia.

Executive Functions and Student Success During Physical Therapist Education: An Exploratory Study.

BACKGROUND: Clinical reasoning relies on executive functions (EFs) that manage attention, inhibition, organization, and decision-making. Assessment of EFs may help identify students who excel at clinical reasoning, yet data showing this relationship in physical therapy (PT) education programs are lacking. The primary purpose of this exploratory study was to examine EFs in relationship to success in PT educational programs. METHODS: Thirteen third-year PT graduate students completed two EF tests which were compared to culminating scores in the program and admissions scores. RESULTS: A relationship existed between National Physical Therapy Examination (NPTE) and comprehensive exam results and one EF test score; comprehensive exams and NPTE scores related to the other EF test. CONCLUSIONS: EF measures may provide insights into student successes, especially as they pertain to outcomes requiring clinical reasoning.

Cognitive Assessments for Patients With Neurological Conditions: A Preliminary Survey of Speech-Language Pathology Practice Patterns.

Purpose Speech-language pathologists (SLPs) are often responsible for assessing cognitive disorders that affect communication for individuals with diagnosed or suspected acute or degenerative neurological conditions. However, consensus on appropriate assessment tools for various neurological disorders remains elusive. This preliminary survey was conducted to study current practices in the use of published and unpublished tools by SLPs when assessing cognitive-communication impairments across common neurologic conditions. Method An 18-item web-based survey was sent to SLPs through ASHA Communities and social media, asking them to select which cognitive assessment tools they use to evaluate the cognitive-communication status of individuals with Parkinson's disease, multiple sclerosis, dementia, stroke (i.e., cerebrovascular accident), and traumatic brain injury. The 100 SLPs who completed the online survey represent a spectrum of professionals seeing neurologic patients across the United States. Results Among the 100 responding SLPs, no unique pattern of assessment tool use was noted across neurologic disorders as indicated by a chi-square analysis. A common set of nonstandardized and observational assessment practices was reported most commonly, regardless of the neurologic condition. Conclusions This study shows consistent cognitive assessment practices by SLPs across various neurological conditions rather than unique protocols relevant to the patterns typical across disorders. However, the amount of clinical evaluations supported by informal observation and/or the completion of select subtests of standardized assessment tools is considerable. This preliminary information conflicts with principles of rigorous assessment and increases the risk of erroneous findings when identifying cognitive impairments. Further research into the decision-making process of clinician assessment selection is warranted to encourage consistent, evidence-based practice for persons with cognitive impairments. Better recognition of the limitations imposed by providing clinical services that impact the reliability and validity of cognitive assessments can drive future clinical practice policy and practice recommendations.

Neuroplasticity and aphasia treatments: new approaches for an old problem.

Given the profound impact of language impairment after stroke (aphasia), neuroplasticity research is garnering considerable attention as means for eventually improving aphasia treatments and how they are delivered. Functional and structural neuroimaging studies indicate that aphasia treatments can recruit both residual and new neural mechanisms to improve language function and that neuroimaging modalities may hold promise in predicting treatment outcome. In relatively small clinical trials, both non-invasive brain stimulation and behavioural manipulations targeting activation or suppression of specific cortices can improve aphasia treatment outcomes. Recent language interventions that employ principles consistent with inducing neuroplasticity also are showing improved performance for both trained and novel items and contexts. While knowledge is rapidly accumulating, larger trials emphasising how to select optimal paradigms for individualised aphasia treatment are needed. Finally, a model of how to incorporate the growing knowledge into clinical practice could help to focus future research.

Quality Appraisal of Systematic Reviews for Behavioral Treatments of Attention Disorders in Traumatic Brain Injury.

OBJECTIVE: This review appraised the quality of systematic reviews (SRs) and meta-analyses (MAs) to summarize research on behavioral interventions for attention disorders in persons with traumatic brain injury. METHODS: A search of 7 databases revealed 15 MAs/SRs reporting outcomes for attention treatments in traumatic brain injury. Two examiners independently coded the quality of reviews with the Critical Appraisal of Systematic Review or Meta-Analysis and the Evidence in Augmentative and Alternative Communication Systematic Review Scale. RESULTS: The findings of both scales were highly correlated. Four reviews were conducted with high methodologic rigor indicated by a score of 60% or greater on both scales. No other study scored above 45%. Among the well-conducted SRs/MAs, evidence for direct attention training effects was limited to basic attention exercises, with little generalization to functional activities. Strategy training for activities and tasks requiring attentional abilities had a stronger evidence base in 1 rigorous MA. CONCLUSIONS: This appraisal provides valuable practice information. The conclusions of 4 rigorous reviews suggest that there is only limited positive scientific support for the effects of attention treatments for traumatic brain injury. Future SRs/MAs would benefit from adherence to review guidelines.

Critical appraisal of systematic reviews of executive function treatments in TBI.

OBJECTIVE: To appraise the quality of systematic reviews (SRs) and meta-analyses (MAs) that summarize the treatment literature for executive function (EF) impairments following traumatic brain injury (TBI). METHODS: We used five data sources (PubMed; PsycINFO; ANCDS.org; Cochrane Collaboration; American Speech-Language-Hearing Association Compendium; Psychological Database for Brain Impairment Treatment Efficacy) and identified 19 reviews that met eligibility criteria (adults with TBI; behavioural treatments for EF impairments; no pharmacologic treatments). Two reviewers independently and reliably rated each paper using two appraisal tools (Critical Appraisal of Systematic Review or Meta-Analysis and Evidence in Augmentative and Alternative Communication systematic review scale). RESULTS: Five MAs received highest ratings. Four SRs also addressed the majority of SR criteria. Reviews were better at addressing SR criteria as outcome measures across studies varied considerably, posing a challenge to quantitatively synthesize TBI outcomes. The strongest research evidence favours compensatory treatments that train individuals with TBI to use strategies to circumvent EF impairments in daily activities. Smaller effects are reported for direct training approaches. CONCLUSIONS: Researchers need to identify core outcome measures to facilitate future rigorous MAs of the EF rehabilitation literature. SRs/MAs need to be conducted with thorough methods that are reported with detail.

Communication Partner Training in Aphasia: An Updated Systematic Review.

OBJECTIVES: To update a previous systematic review describing the effect of communication partner training on individuals with aphasia and their communication partners, with clinical questions addressing effects of partner training on language, communication activity/participation, psychosocial adjustment, and quality of life. DATA SOURCES: Twelve electronic databases were searched using 23 search terms. References from relevant articles were hand searched. STUDY SELECTION: Three reviewers independently reviewed abstracts, excluding those that failed to meet inclusion criteria. Thirty-two full text articles were reviewed by 2 independent reviewers. Articles not meeting inclusion criteria were eliminated, resulting in a corpus of 25 articles for full review. DATA EXTRACTION: For the 25 articles, 1 reviewer extracted descriptive data regarding participants, intervention, outcome measures, and results. A second reviewer verified the accuracy of the extracted data. DATA SYNTHESIS: The 3-member review team classified studies using the American Academy of Neurology levels of evidence. Two independent reviewers evaluated each article using design-specific tools to assess research quality. CONCLUSIONS: All 25 of the current review articles reported positive changes from partner training. Therefore, to date, 56 studies across 2 systematic reviews have reported positive outcomes from communication partner training in aphasia. The results of the current review are consistent with the previous review and necessitate no change to the earlier recommendations, suggesting that communication partner training should be conducted to improve partner skill in facilitating the communication of people with chronic aphasia. Additional high-quality research is needed to strengthen the original 2010 recommendations and expand recommendations to individuals with acute aphasia. High-quality clinical trials are also needed to demonstrate implementation of communication partner training in complex environments (eg, health care).

Development of Trivia Game for speech understanding in background noise.

PURPOSE: Listening in noise is an everyday activity and poses a challenge for many people. To improve the ability to understand speech in noise, a computerized auditory rehabilitation game was developed. In Trivia Game players are challenged to answer trivia questions spoken aloud. As players progress through the game, the level of background noise increases. A study using Trivia Game was conducted as a proof-of-concept investigation in healthy participants. METHOD: College students with normal hearing were randomly assigned to a control (n = 13) or a treatment (n = 14) group. Treatment participants played Trivia Game 12 times over a 4-week period. All participants completed objective (auditory-only and audiovisual formats) and subjective listening in noise measures at baseline and 4 weeks later. RESULT: There were no statistical differences between the groups at baseline. At post-test, the treatment group significantly improved their overall speech understanding in noise in the audiovisual condition and reported significant benefits in their functional listening abilities. CONCLUSION: Playing Trivia Game improved speech understanding in noise in healthy listeners. Significant findings for the audiovisual condition suggest that participants improved face-reading abilities. Trivia Game may be a platform for investigating changes in speech understanding in individuals with sensory, linguistic and cognitive impairments.

An International Perspective on Quality of Life in Aphasia: A Survey of Clinician Views and Practices from Sixteen Countries.

OBJECTIVE: To gain an insight into speech and language therapists' perspectives on and practices in quality of life in aphasia. PARTICIPANTS AND METHODS: The International Association of Logopedics and Phoniatrics Aphasia Committee developed a survey questionnaire, which was delivered online, anonymously, through SurveyMonkey (November 2012 to April 2013) to clinicians working with people with aphasia in 16 countries across the world. RESULTS: A large number of speech and language therapists responded to the survey, with 19/21 questions answered by 385-579 participants. Clinicians were well informed on what constitutes quality of life and viewed it as a complex construct influenced by health, participation, in/dependence, communication, personal factors, and environmental factors. In their clinical practice, they considered quality of life as important, used informal approaches to explore it and aimed to address quality of life goals; yet, the majority did not evaluate quality of life in a systematic way. CONCLUSION: There is a need for training on quality of life to help speech and language therapists incorporate quality of life outcome measures in their interventions. There is also a need for further research on which interventions improve quality of life in aphasia.

Psychosocial treatments for ADHD: a systematic appraisal of the evidence.

OBJECTIVE: Children with learning disabilities often experience comorbid ADHD, impacting on the effectiveness of interventions for those children. In addition to pharmacologic intervention, clinicians and educators employ a variety of psychosocial methods to address the behavioral and social issues that arise in children with ADHD, including those with co-occurring learning disabilities. Numerous systematic reviews and meta-analyses have been conducted examining treatment studies using psychosocial interventions for children with ADHD. Because of the importance of such reviews to evidence based clinical and educational practice, it is essential that reviews be conducted with rigorous methodologies to avoid bias in conclusions (Schlosser, Wendt, & Sigafoos, 2007). The purpose of this study was to evaluate the quality of systematic reviews and meta-analyses conducted for psychosocial treatments of ADHD in children. METHOD: Electronic databases were searched for peer-reviewed, English language studies of psychosocial treatments for ADHD in children up to 18-years-old from 1998 to 2010. Twenty-one studies were identified that met inclusion criteria (13 systematic reviews, 8 meta-analyses). Independent examiners used the quality rating scale proposed by Auperin, Pignon, and Pynard (1997) to rate the characteristics of good systematic reviews and meta-analyses. RESULTS: Results indicated that certain methodological characteristics were common across trials reviewed, yet shortcomings were common among most reviews, including inadequate descriptions of data extraction methods and lack of quality ratings for trials included in the reviews. CONCLUSION: Synthesis of findings from the five top-rated reviews and the literature on ADHD suggest that psychosocial treatments contribute to improvements on behavioral and social outcomes. How ADHD and LD interplay in treatment outcomes is largely unexplored.

Anomia treatment platform as behavioral engine for use in research on physiological adjuvants to neurorehabilitation.

The purpose of this study was to create a "behavioral treatment engine" for future use in research on physiological adjuvants in aphasia rehabilitation. We chose the behavioral target anomia, which is a feature displayed by many persons who have aphasia. Further, we wished to saturate the treatment approach with many strategies and cues that have been empirically reported to have a positive influence on aphasia outcome, with the goal being to optimize the potential for positive response in most participants. A single-subject multiple baseline design with replication across eight participants was employed. Four men and four women, with an average age of 62 yr and an average of 63.13 mo poststroke onset, served as participants. Word-retrieval treatment was administered 3 d/wk, 1 h/d for a total of 20 treatment hours (6-7 wk). Positive acquisition effects were evident in all eight participants (d effect size [ES] = 5.40). Treatment effects were maintained 3 mo after treatment termination for five participants (d ES = 2.94). Within and across semantic category, generalization was minimal (d ES = 0.43 within and 1.09 across). This study demonstrates that this behavioral treatment engine provides a solid platform on which to base future studies whereby various treatment conditions are manipulated and pharmacologic support is added.

Effects of noise and audiovisual cues on speech processing in adults with and without ADHD.

OBJECTIVE: This study examined the interplay among internal (e.g. attention, working memory abilities) and external (e.g. background noise, visual information) factors in individuals with and without ADHD. DESIGN: A 2 × 2 × 6 mixed design with correlational analyses was used to compare participant results on a standardized listening in noise sentence repetition task (QuickSin; Killion et al, 2004 ), presented in an auditory and an audiovisual condition as signal-to-noise ratio (SNR) varied from 25-0 dB and to determine individual differences in working memory capacity and short-term recall. STUDY SAMPLE: Thirty-eight young adults without ADHD and twenty-five young adults with ADHD. RESULTS: Diagnosis, modality, and signal-to-noise ratio all affected the ability to process speech in noise. The interaction between the diagnosis of ADHD, the presence of visual cues, and the level of noise had an effect on a person's ability to process speech in noise. conclusion: Young adults with ADHD benefited less from visual information during noise than young adults without ADHD, an effect influenced by working memory abilities.

Systematic review of communication partner training in aphasia: methodological quality.

Twenty-three studies identified from a previous systematic review examining the effects of communication partner training on persons with aphasia and their communication partners were evaluated for methodological quality. Two reviewers rated the studies on defined methodological quality criteria relevant to each study design. There were 11 group studies, seven single-subject participant design studies, and five qualitative studies. Quality scores were derived for each study. The mean inter-rater reliability of scores for each study design ranged from 85-93%, with Cohen's Kappa indicating substantial agreement between raters. Methodological quality of research on communication partner training in aphasia was highly varied. Overall, group studies employed the least rigorous methodology as compared to single subject and qualitative research. Only two of 11 group studies complied with more than half of the quality criteria. No group studies reported therapist blinding and only one group study reported participant blinding. Across all types of studies, the criterion of treatment fidelity was most commonly omitted. Failure to explicitly report certain methodological quality criteria may account for low ratings. Using methodological rating scales specific to the type of study design may help improve the methodological quality of aphasia treatment studies, including those on communication partner training.

A comparison of intention and pantomime gesture treatment for noun retrieval in people with aphasia.

PURPOSE: The effects of intention gesture treatment (IGT) and pantomime gesture treatment (PGT) on word retrieval were compared in people with aphasia. METHOD: Four individuals with aphasia and word retrieval impairments subsequent to left-hemisphere stroke participated in a single-participant crossover treatment design. Each participant viewed target nouns on a computer screen in 2 counterbalanced training phases. Training included paired verbal + gesture treatment strategies to elicit verbal and/or gestural productions of target nouns. Treatment effects were measured using daily picture-naming probes for verbal naming and gesture productions for trained and untrained words as well as pre-/posttreatment standardized aphasia tests. Outcomes and Results IGT resulted in immediate effects on the verbal productions of 2 participants but lacked carryover to untrained words. PGT resulted in improved verbal production for 2 participants and immediate effects on the gesture productions of 3 participants, with carryover of gesture production to untrained words in 1 participant. Improvements on standardized aphasia tests were evident in 2 participants. CONCLUSION: IGT and PGT had positive treatment effects, but for contrasting communication modalities. Two individuals with mild-moderate aphasia improved verbal production with both IGT and PGT, and 2 individuals with severe aphasia improved gesture use with PGT.

Contrasting effects of errorless naming treatment and gestural facilitation for word retrieval in aphasia.

We compared the effects of two treatments for aphasic word retrieval impairments, errorless naming treatment (ENT) and gestural facilitation of naming (GES), within the same individuals, anticipating that the use of gesture would enhance the effect of treatment over errorless treatment alone. In addition to picture naming, we evaluated results for other outcome measures that were largely untested in earlier ENT studies. In a single participant crossover treatment design, we examined the effects of ENT and GES in eight individuals with stroke-induced aphasia and word retrieval impairments (three semantic anomia, five phonological anomia) in counterbalanced phases across participants. We evaluated effects of the two treatments for a daily picture naming/gesture production probe measure and in standardised aphasia tests and communication rating scales administered across phases of the experiment. Both treatments led to improvements in naming of trained words (small-to-large effect sizes) in individuals with semantic and phonological anomia. Small generalised naming improvements were noted for three individuals with phonological anomia. GES improved use of corresponding gestures for trained words (large effect sizes). Results were largely maintained at one month post-treatment completion. Increases in scores on standardised aphasia testing also occurred for both ENT and GES training. Both ENT and GES led to improvements in naming measures, with no clear difference between treatments. Increased use of gestures following GES provided a potential compensatory means of communication for those who did not improve verbal skills. Both treatments are considered to be effective methods to promote recovery of word retrieval and verbal production skills in individuals with aphasia.