Effects of a Tablet-Based Home Practice Program With Telepractice on Treatment Outcomes in Chronic Aphasia.

Purpose: The aim of this study was to determine if a tablet-based home practice program with weekly telepractice support could enable long-term maintenance of recent treatment gains and foster new language gains in poststroke aphasia. Method: In a pre-post group study of home practice outcomes, 21 individuals with chronic aphasia were examined before and after a 6-month home practice phase and again at follow-up 4 months later. The main outcome measure studied was change in naming previously treated or untreated, practiced or unpracticed pictures of objects and actions. Individualized home practice programs were created in iBooks Author with semantic, phonemic, and orthographic cueing in pictures, words, and videos in order to facilitate naming of previously treated or untreated pictures. Results: 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. There was a negative relationship between the amount of training required for iPad proficiency and improvements on practiced and unpracticed pictures and a positive relationship between practice compliance and same improvements. Conclusion: Unsupervised home practice with weekly video teleconferencing support is effective. This study demonstrates that even individuals with chronic severe aphasia, including those with no prior smart device or even computer experience, can attain independent proficiency to continue practicing and improving their language skills beyond therapy discharge. This could represent a low-cost therapy option for individuals without insurance coverage and/or those for whom mobility is an obstacle to obtaining traditional aphasia therapy.

Practice effects in healthy older adults: Implications for treatment-induced neuroplasticity in Aphasia.

In treating aphasic individuals with anomia, practice naming pictures leads to better performance as measured by accuracy and reaction time. The neurocognitive mechanisms supporting such improvements remain elusive, in part due to gaps in understanding the influence of practice on neurotypical older adults. The current study investigated the influence of practice naming one set of low frequency pictures of actions and objects in 18 healthy older adults, ten of whom were tested twice approximately one month apart. Both item and task practice effects were observed in improved accuracy and response latencies naming pictures in the scanner. This same facilitation effect was observed in neuroimaging results. For example, a significant main effect of practice was observed in bilateral precuneus and left inferior parietal lobule, characterized by greater activity for naming practiced vs. unpracticed pictures. This difference was significantly diminished in subsequent runs after exposure to unpracticed pictures. Whole brain analyses across two sessions showed that practice effects were specific to practice, i.e., there were not similar observable changes in contrasts examining actions vs. objects over time. These findings have important implications for understanding treatment-induced neuroplasticity in anomia treatment.

Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint.

Purpose: Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical. Method: Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality. Results: All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant. Conclusion: Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Beyond picture naming: norms and patient data for a verb-generation task.

PURPOSE: In the current study, the authors aimed to (a) acquire a set of verb generation to picture norms; and (b) probe its utility as an outcomes measure in aphasia treatment. METHOD: In Phase I, the verb-generation normative sample, 50 healthy volunteers generated verbs for 218 pictures of common objects (interstimulus interval = 5 s). In Phase II, 4 persons with aphasia (PWAs) generated verbs for 60 objects (interstimulus interval = 10 s). Their stimuli consisted of objects that were (a) recently trained (for object naming; n = 20), (b) untrained (a control set; n = 20), or (c) from a set of pictures named correctly at baseline (n = 20). Verb generation was acquired twice: once 2 months into and once following a 6-month home practice program. RESULTS: No objects elicited perfect verb agreement in the normed sample. Stimuli with the highest percent agreement were mostly artifacts and dominant verbs primary functional associates. Although not targeted in treatment or home practice, PWAs mostly improved performance in verb generation postpractice. CONCLUSIONS: A set of clinically and experimentally useful verb-generation norms was acquired for a subset of the Snodgrass and Vanderwart (1980) picture set. More cognitively demanding than confrontation naming, this task may help to fill the sizeable gap between object picture naming and propositional speech.

iPractice: piloting the effectiveness of a tablet-based home practice program in aphasia treatment.

The current study investigated the effectiveness of a home practice program based on the iPad (Apple Inc., Cupertino, CA), implemented after 2 weeks of intensive language therapy, for maintaining and augmenting treatment gains in people with chronic poststroke aphasia. Five of eight original participants completed the 6-month home practice program in which they autonomously practiced retrieving words for objects and actions. Half of these words had been trained and half were untrained during therapy. Practice included tasks such as naming to confrontation, repeating from a video model, and picture/word matching presented on an iPad. All participants maintained advances made on words trained during the intensive treatment and additionally were able to learn new words by practicing daily over a 6-month period. The iPad and other tablet devices have great potential for personalized home practice to maintain and augment traditional aphasia rehabilitation. It appears that motivation to use the technology and adequate training are more important factors than age, aphasia type or severity, or prior experience with computers.

Constrained versus unconstrained intensive language therapy in two individuals with chronic, moderate-to-severe aphasia and apraxia of speech: behavioral and fMRI outcomes.

PURPOSE: This Phase I study investigated behavioral and functional MRI (fMRI) outcomes of 2 intensive treatment programs to improve naming in 2 participants with chronic moderate-to-severe aphasia with comorbid apraxia of speech (AOS). Constraint-induced aphasia therapy (CIAT; Pulvermüller et al., 2001) has demonstrated positive outcomes in some individuals with chronic aphasia. Whether constraint to the speech modality or treatment intensity is responsible for such gains is still under investigation. Moreover, it remains to be seen whether CIAT is effective in individuals with persistent severe nonfluent speech and/or AOS. METHOD: A single-subject multiple-baseline approach was used. Both participants were treated simultaneously, first with Promoting Aphasics' Communicative Effectiveness (PACE; Davis & Wilcox, 1985) and then with CIAT. Pre-/posttreatment testing included an overt naming fMRI protocol. Treatment effect sizes were calculated for changes in probe accuracy from baseline to posttreatment phases and maintenance where available. RESULTS: Both participants made more and faster gains in naming following CIAT. Treatment-induced changes in BOLD activation suggested that better naming was correlated with the recruitment of perilesional tissue. CONCLUSION: Participants produced more target words accurately following CIAT than following PACE. Behavioral and fMRI results support the notion that the intense and repetitive nature of obligatory speech production in CIAT has a positive effect on word retrieval, even in participants with chronic moderate-to-severe aphasia with comorbid AOS.

Effects of cognate status and language of therapy during intensive semantic naming treatment in a case of severe nonfluent bilingual aphasia.

As bilingualism becomes less exceptional in the world, and with the growing incidence of stroke and aphasia, a better understanding of how bilingualism affects aphasia recovery is increasingly important. The present study examined the effect of intensive semantic naming therapy in three phases (Spanish, English and mixed) on within- and across-language generalization for cognates and non-cognates, in a bilingual individual with chronic, severe expressive aphasia. We hypothesized that cognates would positively influence cross-linguistic generalization, which might be more likely to occur from L2 to L1. Results indicate relative increases in confrontation naming ability in the following conditions: trained versus untrained, L1 versus L2 or mixed and non-cognates versus cognates. This participant demonstrated a pattern of results consistent with a differential recovery pattern in which presentation of treatment in both languages and training of cognates may have promoted interference, thus increasing the activation threshold, and lowering performance under these conditions.

Overt naming fMRI pre- and post-TMS: Two nonfluent aphasia patients, with and without improved naming post-TMS.

Two chronic, nonfluent aphasia patients participated in overt naming fMRI scans, pre- and post-a series of repetitive transcranial magnetic stimulation (rTMS) treatments as part of a TMS study to improve naming. Each patient received 10, 1-Hz rTMS treatments to suppress a part of R pars triangularis. P1 was a 'good responder' with improved naming and phrase length; P2 was a 'poor responder' without improved naming. Pre-TMS (10 years poststroke), P1 had significant activation in R and L sensorimotor cortex, R IFG, and in both L and R SMA during overt naming fMRI (28% pictures named). At 3 mo. post-TMS (42% named), P1 showed continued activation in R and L sensorimotor cortex, R IFG, and in R and L SMA. At 16 mo. post-TMS (58% named), he also showed significant activation in R and L sensorimotor cortex mouth and R IFG. He now showed a significant increase in activation in the L SMA compared to pre-TMS and at 3 mo. post-TMS (p < .02; p < .05, respectively). At 16 mo. there was also greater activation in L than R SMA (p < .08). At 46 mo. post-TMS (42% named), this new LH pattern of activation continued. He improved on the Boston Naming Test from 11 pictures named pre-TMS, to scores ranging from 14 to 18 pictures, post-TMS (2-43 mo. post-TMS). His longest phrase length (Cookie Theft picture) improved from three words pre-TMS, to 5-6 words post-TMS. Pre-TMS (1.5 years poststroke), P2 had significant activation in R IFG (3% pictures named). At 3 and 6 mo. post-TMS, there was no longer significant activation in R IFG, but significant activation was present in R sensorimotor cortex. On all three fMRI scans, P2 had significant activation in both the L and R SMA. There was no new, lasting perilesional LH activation across sessions for this patient. Over time, there was little or no change in his activation. His naming remained only at 1-2 pictures during all three fMRI scans. His BNT score and longest phrase length remained at one word, post-TMS. Lesion site may play a role in each patient's fMRI activation pattern and response to TMS treatment. P2, the poor responder, had an atypical frontal lesion in the L motor and premotor cortex that extended high, near brain vertex, with deep white matter lesion near L SMA. P2 also had frontal lesion in the posterior middle frontal gyrus, an area important for naming (Duffau et al., 2003); P1 did not. Additionally, P2 had lesion inferior and posterior to Wernicke's area, in parts of BA 21 and 37, whereas P1 did not. The fMRI data of our patient who had good response following TMS support the notion that restoration of the LH language network is linked in part, to better recovery of naming and phrase length in nonfluent aphasia.

Neural Mechanisms Underlying Learning following Semantic Mediation Treatment in a case of Phonologic Alexia.

Patients with phonologic alexia can be trained to read semantically impoverished words (e.g., functors) by pairing them with phonologically-related semantically rich words (e.g, nouns). What mechanisms underlie success in this cognitive re-training approach? Does the mechanism change if the skill is "overlearned", i.e., practiced beyond criterion? We utilized fMRI pre- and post-treatment, and after overlearning, to assess treatment-related functional reorganization in a patient with phonologic alexia, two years post left temporoparietal stroke. Pre-treatment, there were no statistically significant differences in activation profiles across the sets of words. Post-treatment, accuracy on the two trained sets improved. Compared with untrained words, reading trained words recruited larger and more significant clusters of activation in the right hemisphere, including right inferior frontal and inferior parietal cortex. Post-overlearning, with near normal performance on overlearned words, predominant activation shifted to left hemisphere regions, including perilesional activation in superior parietal lobe, when reading overlearned vs. untrained words.

Improved naming after TMS treatments in a chronic, global aphasia patient--case report.

We report improved ability to name pictures at 2 and 8 months after repetitive transcranial magnetic stimulation (rTMS) treatments to the pars triangularis portion of right Broca's homologue in a 57 year-old woman with severe nonfluent/global aphasia (6.5 years post left basal ganglia bleed, subcortical lesion). TMS was applied at 1 Hz, 20 minutes a day, 10 days, over a two-week period. She received no speech therapy during the study. One year after her TMS treatments, she entered speech therapy with continued improvement. TMS may have modulated activity in the remaining left and right hemisphere neural network for naming.

Overt naming in aphasia studied with a functional MRI hemodynamic delay design.

The purpose of this study was to develop a functional MRI method to examine overt speech in stroke patients with aphasia. An fMRI block design for overt picture naming was utilized which took advantage of the hemodynamic response delay where increased blood flow remains for 4-8 s after the task [(Friston, K.J., Jezzard, P., Turner, R., 1994. Analysis of functional MRI time-series. Hum. Brain Mapp. 1, 153-171)]. This allowed task-related information to be obtained after the task, minimizing motion artifact from overt speech (Eden, G.F., Joseph, J., Brown, H.E., Brown, C.P., Zeffiro, T.A., 1999. Utilizing hemodynamic delay and dispersion to detect fMRI signal change without auditory interference: the behavior interleaved gradients technique. Magn. Reson. Med. 41, 13-20; Birn, RM., Bandettini, P.A., Cox, R.W., Shaker, R., 1999. Event-related fMRI of tasks involving brief motion. Hum. Brain Mapp. 7, 106-114; Birn, R.M., Cox, R.W., Bandettini, P.A., 2004. Experimental designs and processing strategies for fMRI studies involving overt verbal responses. NeuroImage 23, 1046-1058). Five chronic aphasia patients participated (4 mild-moderate and 1 severe nonfluent/global). The four mild-moderate patients who correctly named 88-100% of the pictures during fMRI, had a greater number of suprathreshold voxels in L supplementary motor area (SMA) than R SMA (P < 0.07). Three of these four mild-moderate patients showed activation in R BA 45 and/or 44; along with L temporal and/or parietal regions. The severe patient, who named no pictures, activated almost twice as many voxels in R SMA than L SMA. He also showed activation in R BA 44, but had remarkably extensive L and R temporal activation. His poor naming and widespread temporal activation may reflect poor modulation of the bi-hemispheric neural network for naming. Results indicate that this fMRI block design utilizing hemodynamic response delay can be used to study overt naming in aphasia patients, including those with mild-moderate or severe aphasia. This method permitted verification that the patients were cooperating with the task during fMRI. It has application for future fMRI studies of overt speech in aphasia.

Improved picture naming in chronic aphasia after TMS to part of right Broca's area: an open-protocol study.

Functional imaging studies with nonfluent aphasia patients have observed "over-activation" in right (R) language homologues. This may represent a maladaptive strategy; suppression may result in language improvement. We applied slow, 1 Hz repetitive transcranial magnetic stimulation (rTMS) to an anterior portion of R Broca's homologue daily, for 10 days in four aphasia patients who were 5-11 years poststroke. Significant improvement was observed in picture naming at 2 months post-rTMS, with lasting benefit at 8 months in three patients. This preliminary, open trial suggests that rTMS may provide a novel treatment approach for aphasia by possibly modulating the distributed, bi-hemispheric language network.

Transcranial magnetic stimulation as a complementary treatment for aphasia.

Functional brain imaging with nonfluent aphasia patients has shown increased cortical activation (perhaps "overactivation") in right (R) hemisphere language homologues. These areas of overactivation may represent a maladaptive strategy that interferes with, rather than promotes, aphasia recovery. Repetitive transcranial magnetic stimulation (rTMS) is a painless, noninvasive procedure that utilizes magnetic fields to create electric currents in discrete brain areas affecting about a 1-cm square area of cortex. Slow frequency, 1 Hz rTMS reduces cortical excitability. When rTMS is applied to an appropriate cortical region, it may suppress the possible overactivation and thus modulate a distributed neural network for language. We provide information on rTMS and report preliminary results following rTMS application to R Broca's area (posterior, R pars triangularis) in four stroke patients with nonfluent aphasia (5-11 years after left hemisphere stroke). Following 10 rTMS treatments, significant improvement in naming pictures was observed. This form of rTMS may provide a novel, complementary treatment for aphasia.

Test-retest reliability of fMRI during nonverbal semantic decisions in moderate-severe nonfluent aphasia patients.

Cortical reorganization in poststroke aphasia is not well understood. Few studies have investigated neural mechanisms underlying language recovery in severe aphasia patients, who are typically viewed as having a poor prognosis for language recovery. Although test-retest reliability is routinely demonstrated during collection of language data in single-subject aphasia research, this is rarely examined in fMRI studies investigating the underlying neural mechanisms in aphasia recovery. The purpose of this study was to acquire fMRI test-retest data examining semantic decisions both within and between two aphasia patients. Functional MRI was utilized to image individuals with chronic, moderate-severe nonfluent aphasia during nonverbal, yes/no button-box semantic judgments of iconic sentences presented in the Computer-assisted Visual Communication (C-ViC) program. We investigated the critical issue of intra-subject reliability by exploring similarities and differences in regions of activation during participants' performance of identical tasks twice on the same day. Each participant demonstrated high intra-subject reliability, with response decrements typical of task familiarity. Differences between participants included greater left hemisphere perilesional activation in the individual with better response to C-ViC training. This study provides fMRI reliability in chronic nonfluent aphasia, and adds to evidence supporting differences in individual cortical reorganization in aphasia recovery.