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Purpose: Evaluation of the Naming and Oral Reading for Language in Aphasia 6-point scale (NORLA-6), a scoring system of oral reading and naming performance in aphasia., Method: Data were drawn from 91 participants with non-fluent aphasia secondary to left-hemisphere stroke across four treatment studies. To assess validity, Spearman's correlations were calculated between the NORLA-6 and the Gray Oral Reading Test-Fourth Edition (GORT-4) Accuracy score, GORT-4 Rate score and the Boston Naming Test (BNT). Inter-rater and test-retest reliability were evaluated using correlations. Sensitivity to change following oral reading intervention was analysed using Wilcoxon Signed Rank tests between pre- and post-treatment NORLA-6 scores., Result: NORLA-6 performance was significantly correlated (p < 0.001) with all reference tests (GORT-4 Accuracy, r s =0.84; GORT-4 Rate, r s = 0.61; and BNT, r s = 0.92). Inter-rater (ICC ≥0.90) and test-retest (r > 0.92) reliability were both excellent. Sensitivity following oral reading intervention was demonstrated in both oral reading accuracy and rate (p < 0.004)., Conclusion: The NORLA-6 is a valid and reliable measure of oral reading and naming performance. It also demonstrates sensitivity to change in treatment-targeted behaviours. Therefore, the NORLA-6 scale may enhance outcome measurement in both clinical practice and aphasia research.

Purpose: Tau-U is a quantitative approach for analyzing single-case experimental design (SCED) data. It combines nonoverlap between phases with intervention phase trend and can correct for a baseline trend (Parker, Vannest, & Davis, 2011). We demonstrate the utility of Tau-U by comparing it with the standardized mean difference approach (Busk & Serlin, 1992) that is widely reported within the aphasia SCED literature., Method: Repeated writing measures from 3 participants with chronic aphasia who received computer-based writing treatment are analyzed visually and quantitatively using both Tau-U and the standardized mean difference approach., Results: Visual analysis alone was insufficient for determining an effect between the intervention and writing improvement. The standardized mean difference yielded effect sizes ranging from 4.18 to 26.72 for trained items and 1.25 to 3.20 for untrained items. Tau-U yielded significant (p < .05) effect sizes for 2 of 3 participants for trained probes and 1 of 3 participants for untrained probes. A baseline trend correction was applied to data from 2 of 3 participants., Conclusions: Tau-U has the unique advantage of allowing for the correction of an undesirable baseline trend. Although further study is needed, Tau-U shows promise as a quantitative approach to augment visual analysis of SCED data in aphasia.

Background: Recent imaging studies indicate that aphasia is associated with large-scale reorganization of brain networks. Today, neuroimaging studies show that various brain connectivity properties, as measured by resting state fMRI, can partially explain different behavioral symptoms in and across various patient groups. Despite these observations, the neural networks underlying the progress and recovery of aphasia following intensive treatment remains relatively obscure., Objective: To examine the role of brain network properties in determining recovery of aphasia following intensive therapy in stroke patients., Methods: We studied eight patients with left hemispheric lesions who completed an intensive comprehensive aphasia program (ICAP). Language and cognition were assessed before and after four weeks of intensive treatment. In addition, all patients underwent resting state fMRI prior to and after treatment. We used graph theory analysis to evaluate relationships of baseline brain network properties, such as efficiency, modularity, and connectivity to clinical improvements., Results: We found global properties such as efficiency and interhemispheric connectivity could partially explain recovery. More importantly, we identified two unique brain networks that are significantly associated with improvement in language and attention related behavior., Conclusions: These results suggest baseline brain functional properties play a key role in determining responsiveness of patients with aphasia to intensive comprehensive aphasia treatment. Furthermore, these results indicate that brain mechanisms underlying language comprehension and processes are different from those involved in spatial attention.

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)., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke., Methods: Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee., Results: Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential., Conclusions: As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.)., (© 2016 American Heart Association, Inc.)

Background: Intensity of therapy is a critical factor influencing outcomes in aphasia. However, there are many barriers to increasing treatment intensity for those with acute/subacute aphasia including the demands of the inpatient medical facilities and the endurance of the participants. Nevertheless, with some modifications to its original procedures, evidence suggests that Constraint Induced Language Therapy (CILT) may yield positive outcomes when given in the early stages of recovery., Aims: To investigate the feasibility of increasing the amount of therapy provided to individuals with aphasia on an inpatient rehabilitation unit by adding CILT at a modified intensity, and to assess whether those receiving two weeks of the additional CILT show more improvement than control participants who did not receive the additional treatment., Methods and Procedures: A case-series single-subject design study was conducted. All participants received usual care of approximately an hour of speech and language treatment, five to six days a week. Participants in the experimental condition received an additional hour-long CILT session, five days per week, for two weeks. Trained, untrained, and generalization probes comprising naming of pictured items and oral reading of sentences were taken at baseline, during treatment, and at post-treatment. All participants were probed equally. Probe performance was scored and effect sizes were calculated and compared. Performance gains from pre- to post-treatment on subtests of the Boston Diagnostic Aphasia Examination were also compared., Outcomes and Results: Thirteen individuals with aphasia onset ranging from 7 to 68 days were recruited, with 6 allocated to the experimental Usual Care + CILT condition and 7 allocated to the control Usual Care condition. Increasing the amount of speech and language therapy by adding an hour of daily CILT was feasible. Individual performance varied within and across conditions with large gains noted in some, but not all participants. As a group, there was a small to medium effect size of the Usual Care + CILT condition over Usual Care alone for trained and untrained oral reading probes and untrained naming probes., Conclusions: It is feasible to increase the amount of treatment provided to participants with aphasia on an acute inpatient rehabilitation unit. Preliminary results suggest that there may be better outcomes for those who receive more treatment. Further research using larger numbers of homogeneous participants and controlling for content of therapy as well as amount of therapy is warranted.

Purpose: Script training for aphasia involves repeated practice of relevant phrases and sentences that, when mastered, can potentially be used in other communicative situations. Although an increasingly popular approach, script development can be time-consuming. We provide a detailed summary of the evidence supporting this approach. We then describe a method in which scripts at various levels of difficulty are created by systematically manipulating readability and grammatical and semantic components. We assess the appropriateness of using these template-based scripts with persons with aphasia of differing severities., Method: We evaluated the oral reading performance of eight individuals with chronic non-fluent aphasia on scripts developed from the templates. Scripts were either of high or low difficulty relative to their aphasia severity, and personalized by inserting the participant's town and the name of an acquaintance. Oral reading probes were taken on three separate days within a week and performance within and across participants was examined., Results: Regardless of the participant's aphasia severity, scripts in the low-difficulty condition were read with significantly greater accuracy than scripts in the high-difficulty condition., Discussion: These findings support the use of graded script templates to ensure that appropriately challenging scripts are delivered to persons with aphasia for both clinical practice and research.

Background: There is increasing interest in the application of cortical stimulation (CS) as an adjuvant strategy in aphasia rehabilitation. Epidural CS, although more invasive than other methods, can provide high-frequency ipsilesional stimulation with greater spatial specificity., Objective: We review methods and results of a phase 1 study of epidural CS in combination with rehabilitation therapy in aphasia and provide new objective and self-report data collected between 6 and 21 months after the end of treatment., Methods: Eight stroke survivors with nonfluent aphasia received intensive language therapy, 3 hours a day, for 6 weeks. Four participants also underwent surgical implantation of an epidural stimulation device that was activated only during therapy sessions. Behavioral data were collected before treatment, at the end of treatment, and at 6 and 12 weeks after the end of treatment. Of the 8 participants, 7 also participated in the longer-term follow-up visit., Results: Changes in objective scores from baseline were larger in investigational participants than controls at all assessments, including the longer-term follow-up visit. Satisfaction ratings and ratings of overall improvement by investigational participants and their companions were more varied than those of the controls, but all indicated that they would recommend the investigational treatment to others with aphasia., Conclusions: Improvements were generally maintained for at least 12 weeks posttreatment and possibly as long as 21 months posttreatment. Epidural CS is a potentially safe, feasible adjunctive intervention for persons with chronic nonfluent aphasia that spares the ventral premotor cortex and warrants further investigation., (© The Author(s) 2015.)

Purpose: The importance of personalization in script training in aphasia has been assumed but never tested. This study compared acquisition and generalization of personally relevant versus generic words or phrases appearing in the same scripts., Method: Eight individuals (6 men; 2 women) with chronic aphasia received 3 weeks of intensive computer-based script training. For each participant, 2 scripts, a trained and an untrained generalization script, were embedded with 4 personally relevant word choices and 2-4 generic items that were similar across participants. Scripts were probed for accuracy at baseline and posttreatment. Significance testing was conducted on baseline and posttreatment scores, and for gains in personally relevant versus generic items. Effect sizes were computed., Results: Both personally relevant and generic items improved significantly on trained scripts. Improvements on untrained scripts were smaller, with only personally relevant items reaching significance. There was no significant difference on gains made on personalized versus generic items for trained scripts (p = .059), but the effect size was large (d = 0.90). For generalization scripts, this effect was small (d = 0.25) and nonsignificant., Conclusions: Personally relevant words and phrases were acquired, although not generalized, more successfully than generic words and phrases. Data supports the importance of personalization in script training, but the degree of that importance requires further investigation.

Purpose: This study describes the structure, processes, and outcomes of an intensive comprehensive aphasia program (ICAP). The aim was to identify treatment gains and determine if outcomes were significantly different between participants grouped according to severity and type of aphasia, and time postonset., Method: Data from 74 first-time ICAP participants were analyzed. Pre- and posttreatment scores on the Western Aphasia Battery-Revised and other impairment and participation measures were compared using paired t tests. Analyses of variance were used to compare outcomes related to aphasia severity (severe, moderate, and mild aphasia), aphasia type (fluent, nonfluent), and chronicity (0-6 months postonset, 7-12 months postonset, and 12+ months postonset)., Results: Participants made significant changes on all impairment and participation measures. Large effect sizes were noted for one participation and three impairment measures. Medium effect sizes were noted for one impairment and three participation measures. There was no significant difference among groups on any factor., Conclusion: ICAPs can have a significant effect on the language impairment and participation of people with aphasia, but further research is required to determine if the effect is comparable to other types of service delivery.

Objective: To systematically review evidence of treatments for cognitive impairments experienced by at least 20% of all women who undergo chemotherapy for breast cancer., Data Sources: Searches of 5 databases (PubMed, Embase, Cochrane CENTRAL, PsycINFO, CINAHL), with no date or language restrictions, identified 1701 unique results. Search terms included breast cancer, chemotherapy, chemobrain, chemofog, and terms on cognition and language deficits., Study Selection: Included only peer-reviewed journal articles that described therapies for cognitive dysfunction in women undergoing (or who had undergone) chemotherapy for breast cancer and provided objective measurements of cognition or language., Data Extraction: Data were extracted according to Cochrane recommendations, including characteristics of participants, interventions, outcomes, and studies. Quality assessment of all 12 eligible studies was performed using the Physiotherapy Evidence Database scale and treatment fidelity criteria. Screening, data extraction, and quality assessment reliability were performed., Data Synthesis: Six articles described interventions for cognition that took place during cancer treatment; 6, afterward. Five interventions were medical (including a strength-training program), 2 were restorative, and 5 were cognitive. Medicinal treatments were ineffective; restorative and exercise treatments had mixed results; cognitive therapy had success in varying cognitive domains. The domains most tested and most successfully treated were verbal memory, attention, and processing speed., Conclusions: Cognitive therapy protocols delivered after chemotherapy and aimed at improving verbal memory, attention, and processing speed hold the most promise. Future research is needed to clarify whether computerized cognitive training can be effective in treating this population, and to identify objective assessment tools that are sensitive to this disorder., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: This study was designed to compare acquisition and maintenance of scripts under two conditions: high cue, which provided numerous multimodality cues designed to minimize errors, and low cue, which provided minimal cues., Method: In a randomized controlled crossover study, eight individuals with chronic aphasia received intensive computer-based script training under two cuing conditions. Each condition lasted 3 weeks, with a 3-week washout period. Trained and untrained scripts were probed for accuracy and rate at baseline, during treatment, immediately posttreatment, and at 3 and 6 weeks posttreatment. Significance testing was conducted on gain scores, and effect sizes were calculated., Results: Training resulted in significant gains in script acquisition with maintenance of skills at 3 and 6 weeks posttreatment. Differences between cuing conditions were not significant. When severity of aphasia was considered, there also were no significant differences between conditions, although magnitude of change was greater in the high-cue condition versus the low-cue condition for those with more severe aphasia., Conclusions: Both cuing conditions were effective in acquisition and maintenance of scripts. The high-cue condition may be advantageous for those with more severe aphasia. Findings support the clinical use of script training and the importance of considering aphasia severity.

A virtual therapist (VT) capable of modeling visible speech and directing speech and language therapy is presented. Three perspectives of practical and clinical use are described. The first is a description of treatment and typical roles that the VT performs in directing participation, practice and performance. The second is a description of techniques for modeling visible speech and implementing tele-rehabilitation. The third is an analysis of performance of a system ( AphasiaRx ™) for delivering speech and language therapy to people with aphasia, with results presented from a randomized controlled cross-over study in which the VT provided two levels of cuing. Compared to low cue treatment, high cue treatment resulted in 2.3 times faster learning. The paper concludes with a discussion of the benefits of speech and language therapy delivered by the VT.

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.

Research into intensive comprehensive aphasia programs (ICAPs) has yet to show that this service delivery model is efficacious, effective, has cost utility, or can be broadly implemented. This article describes a phased research approach to the study of ICAPs and sets out a research agenda that considers not only the specific issues surrounding ICAPs, but also the phase of the research. Current ICAP research is in the early phases, with dosing and outcome measurement as prime considerations as well as refinement of the best treatment protocol. Later phases of ICAP research are outlined, and the need for larger scale collaborative funded research is recognized. The need for more rapid translation into practice is also acknowledged, and the use of hybrid models of phased research is encouraged within the ICAP research agenda.

Background: Intensive comprehensive aphasia programs (ICAPs) have increased in number in recent years in the United States and abroad., Objective: To describe the experiences of clinicians working in an ICAP., Methods: A phenomenological approach was taken. Seven clinicians from 3 ICAPs were interviewed in person or on the phone. Their interviews were transcribed and coded for themes relating to their experiences., Results: Clinicians described 3 major themes. The first theme related to the intensity component of the ICAP that allowed clinicians to provide in-depth treatment and gave them a different perspective with regard to providing treatment and the potential impact on the person with aphasia. The second theme of rewards for the clinicians included learning and support, seeing progress, and developing relationships with their clients and family members. Third, challenges were noted, including the time involved in learning new therapy techniques, patient characteristics such as chronicity of the aphasia, and the difficulty of returning to work in typical clinical settings after having experienced an ICAP., Conclusions: Although there is a potential for bias with the small sample size, this pilot study gives insight into the clinician perspective of what makes working in an ICAP both worthwhile and challenging.

Background: In response to the need to simultaneously address multiple domains of the International Classification of Functioning, Disability and Health (ICF) in aphasia therapy and to incorporate intensive treatment doses consistent with principles of neuroplasticity, a potentially potent treatment option termed intensive comprehensive aphasia programs (ICAPs) has been developed., Objective: To conduct an international survey of ICAPs to determine the extent of their use and to explore current ICAP practices., Methods: A 32-item online survey was distributed internationally through Survey Monkey between May and August 2012. The survey addressed ICAP staffing, philosophy, values, funding, admission criteria, activities, family involvement, outcome measures, and factors considered important to success., Results: Twelve ICAPs responded: 8 from the United States, 2 from Canada, and 1 each from Australia and the United Kingdom. The majority of ICAPs are affiliated with university programs and are funded through participant self-pay. ICAPs emphasize individualized treatment goals and evidence-based practices, with a focus on applying the principles of neuroplasticity related to repetition and intensity of treatment. On average, 6 people with aphasia attend each ICAP, for 4 days per week for 4 weeks, receiving about 100 hours of individual, group, and computer-based treatment. Speech-language pathologists, students, and volunteers staff the majority of ICAPs., Conclusions: ICAPs are increasing in number but remain a rare service delivery option. They address the needs of individuals who want access to intensive treatment and are interested in making significant changes to their communication skills and psychosocial well-being in a short period of time. Their efficacy and cost-effectiveness require future investigation.

The goal of this paper is to discuss experimental design options available for establishing the effects of treatment in studies that aim to examine the neural mechanisms associated with treatment-induced language recovery in aphasia, using functional magnetic resonance imaging (fMRI). We present both group and single-subject experimental or case-series design options for doing this and address advantages and disadvantages of each. We also discuss general components of and requirements for treatment research studies, including operational definitions of variables, criteria for defining behavioral change and treatment efficacy, and reliability of measurement. Important considerations that are unique to neuroimaging-based treatment research are addressed, pertaining to the relation between the selected treatment approach and anticipated changes in language processes/functions and how such changes are hypothesized to map onto the brain., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To illustrate the ethical challenges that arose from investigating a novel treatment procedure, transcranial direct current stimulation (tDCS), in a research participant with aphasia., Method: We review the current evidence supporting the use of tDCS in aphasia research, highlighting methodological gaps in our knowledge of tDCS. Then, we examine the case of Mr. C, a person with chronic aphasia who participated in a research protocol investigating the impact of tDCS on aphasia treatment. We describe the procedures that he underwent and the resulting behavioral and neurophysiological outcomes. Finally, we share the steps that were taken to balance beneficence and nonmaleficence and to ensure Mr. C's autonomy., Results: The objective data show that while Mr. C may not have benefitted from participating in the research, neither did he experience any harm., Conclusion: Researchers must consider not only the scientific integrity of their studies, but also potential ethical issues and consequences to the research participants.

Studies of aphasia treatment have shown that intensive speech-language therapy is associated with significant improvements. However, there is no standard definition of intensity and the simplistic notion that "more is better" is not necessarily supported by the research. First, current evidence regarding intensity and aphasia treatment was briefly summarized. Second, studies that directly compare conditions of higher- and lower-intensity treatment for aphasia were reviewed with regard to the inclusion of parameters that contribute to a definition of intensity. In addition to five parameters proposed by Warren, Fey, and Yoder (2007) and highlighted by Baker (2012) , total number of sessions was also often documented. The review illustrated the complexity of quantifying the dose of comprehensive treatments that target multiple modalities and utilize a variety of different strategies. Third, data from a study reporting a relationship between intensive computer-based script training and outcomes in aphasia were examined. Results serve to illustrate Baker's contention that intensity alone is insufficient without also considering the active ingredients of the teaching episode. Information about dose, therapeutic inputs, and client acts can lead to better optimization of an intervention.

Background: There are several methods of delivering cortical brain stimulation to modulate cortical excitability and interest in their application as an adjuvant strategy in aphasia rehabilitation after stroke is growing. Epidural cortical stimulation, although more invasive than other methods, permits high frequency stimulation of high spatial specificity to targeted neuronal populations., Aims: First, we review evidence supporting the use of epidural cortical stimulation for upper limb recovery after focal cortical injury in both animal models and human stroke survivors. These data provide the empirical and theoretical platform underlying the use of epidural cortical stimulation in aphasia. Second, we summarize evidence for the application of epidural cortical stimulation in aphasia. We describe the procedures and primary outcomes of a safety and feasibility study (Cherney, Erickson & Small, 2010), and provide previously unpublished data regarding secondary behavioral outcomes from that study., Main Contribution: In a controlled study comparing epidural cortical stimulation plus language treatment (CS/LT) to language treatment alone (LT), eight stroke survivors with nonfluent aphasia received intensive language therapy for 6 weeks. Four of these participants also underwent surgical implantation of an epidural stimulation device which was activated only during therapy sessions. Behavioral data were collected before treatment, immediately after treatment, and at 6 and 12 weeks following the end of treatment. The effect size for the primary outcome measure, the Western Aphasia Battery Aphasia Quotient, was benchmarked as moderate from baseline to immediately post-treatment, and large from baseline to the 12-week follow-up. Similarly, effect sizes obtained at the 12-week follow-up for the Boston Naming Test, the Communicative Effectiveness Index, and for correct information units on a picture description task were greater than those obtained immediately post treatment. When effect sizes were compared for individual subject pairs on discourse measures of content and rate, effects were typically larger for the investigational subjects receiving CS/LT than for the control subjects receiving LT alone. These analyses support previous findings regarding therapeutic efficacy of CS/LT compared to LT i.e. epidural stimulation of ipsilesional premotor cortex may augment behavioral speech-language therapy, with the largest effects after completion of therapy., Conclusions: Continued investigation of epidural cortical stimulation in combination with language training in post-stroke aphasia should proceed cautiously. Carefully planned studies that customize procedures to individual profiles are warranted. Information from research on non-invasive methods of CS/LT may also inform future studies of epidural cortical stimulation.

Telerehabilitation (telerehab) offers cost-effective services that potentially can improve access to care for those with acquired neurologic communication disorders. However, regulatory issues including licensure, reimbursement, and threats to privacy and confidentiality hinder the routine implementation of telerehab services into the clinical setting. Despite these barriers, rapid technological advances and a growing body of research regarding the use of telerehab applications support its use. This article reviews the evidence related to acquired neurologic speech and language disorders in adults, focusing on studies that have been published since 2000. Research studies have used telerehab systems to assess and treat disorders including dysarthria, apraxia of speech, aphasia, and mild Alzheimer disease. They show that telerehab is a valid and reliable vehicle for delivering speech and language services. The studies represent a progression of technological advances in computing, Internet, and mobile technologies. They range on a continuum from working synchronously (in real-time) with a speech-language pathologist to working asynchronously (offline) with a stand-in virtual therapist. One such system that uses a virtual therapist for the treatment of aphasia, the Web-ORLA™ (Rehabilitation Institute of Chicago, Chicago, IL) system, is described in detail. Future directions for the advancement of telerehab for clinical practice are discussed., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Determining the optimal amount and intensity of treatment is essential to the design and implementation of any treatment program for aphasia. A growing body of evidence, both behavioral and biological, suggests that intensive therapy positively impacts outcomes. We update a systematic review of treatment studies that directly compares conditions of higher and lower intensity treatment for aphasia. We identify five studies published since 2006, review them for methodologic quality, and synthesize their findings with previous ones. For both acute and chronic aphasia, results at the language impairment and communication activity/participation levels tend to be more equivocal than previously demonstrated, with no clear differences between intensive and nonintensive treatment emerging across studies. Future research directions are discussed including research design, definitions of treatment intensity, and behavioral and biological measurement of short- and long-term changes following implementation of an intensive treatment.

Drama therapy offers an authentic medium through which people with aphasia can interact and share their experiences. We describe the rationale and procedures of a drama class, informed by the principles and practices of drama therapy, in which individuals with chronic aphasia conceptualized, wrote, and produced a play addressing their experiences of having, living with, and coping with the effects of aphasia. Sessions were cofacilitated by a speech-language pathologist and a drama therapist. We describe the drama activities and techniques in each of four distinct stages of a drama therapy process through which the group transitioned. We also summarize patient-reported outcomes of a representational group of seven participants. Subscales of the Burden of Stroke Scale and the Communication Confidence Rating Scale for Aphasia were administered before and after participation in the 18-week class. Means, standard deviations, and effect sizes were computed. Results indicated perceived improvements in both communication and mood., (© Thieme Medical Publishers.)

This study presents results of post-treatment interviews following computer-based script training for persons with chronic aphasia. Each of the 23 participants received 9 weeks of AphasiaScripts training. Post-treatment interviews were conducted with the person with aphasia and/or a significant other person. The 23 interviews yielded 584 coded comments that were categorized into ten themes. Five of the themes related to the communication behaviors of the participant, whereas the other five related to the computer program and study procedures. Examples of each theme are presented. The themes provide qualitative evidence of change and generalization, supporting the use of this computer-based script training program., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Confidence is a construct that has not been explored previously in aphasia research. We developed the Communication Confidence Rating Scale for Aphasia (CCRSA) to assess confidence in communicating in a variety of activities and evaluated its psychometric properties using rating scale (Rasch) analysis. The CCRSA was administered to 21 individuals with aphasia before and after participation in a computer-based language therapy study. Person reliability of the 8-item CCRSA was .77. The 5-category rating scale demonstrated monotonic increases in average measures from low to high ratings. However, one item ("I follow news, sports, stories on TV/movies") misfit the construct defined by the other items (mean square infit = 1.69, item-measure correlation = .41). Deleting this item improved reliability to .79; the 7 remaining items demonstrated excellent fit to the underlying construct, although there was a modest ceiling effect in this sample. Pre- to posttreatment changes on the 7-item CCRSA measure were statistically significant using a paired samples t test. Findings support the reliability and sensitivity of the CCRSA in assessing participants' self-report of communication confidence. Further evaluation of communication confidence is required with larger and more diverse samples.

Objectives: To describe the effects of communication partner training on persons with aphasia and their communication partners. Specifically the systematic review addressed 3 clinical questions regarding the impact of partner training on language, communication activity and participation, psychosocial adjustment, and quality of life for adults with aphasia and their communication partners., Data Sources: Twenty-three terms were used to search 12 electronic databases (eg, PubMed, CINAHL, PsychINFO, PsychArticles, CSA Linguistics and Language Behavior Abstracts, Social Sciences Citation Index [Web of Science], SUMSearch, TRIP, EMBASE, REHABDATA, National Library for Health, Cochrane Database of Systematic Reviews) and the journal "Aphasiology." References from all relevant articles were hand-searched., Study Selection: Two reviewers independently applied inclusion criteria to select potential relevant articles from the titles and abstracts of references retrieved by the literature search. The full text of the remaining articles was reviewed by a 5-member panel, resulting in a corpus of 31 studies that met the final inclusion criteria., Data Extraction: Two independent reviewers extracted the descriptive data related to the participants, the intervention, the outcome measures, and the results., Data Synthesis: The 5-member review team by consensus classified the studies using the American Academy of Neurology system for classification of evidence (2004)., Conclusions: Evidence shows that communication partner training is effective in improving communication activities and/or participation of the communication partner and is probably effective in improving communication activities and/or participation of persons with chronic aphasia when they are interacting with trained communication partners. There is insufficient evidence to make recommendations related to the impact of partner training on persons with acute aphasia or the impact of training on language impairment, psychosocial adjustment, or quality of life for either the person with aphasia or the communication partner., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: This study examined the efficacy of a treatment, Oral Reading for Language in Aphasia (ORLA), delivered by computer to individuals with chronic nonfluent aphasia and compared its efficacy with the same treatment delivered by a speech-language pathologist (SLP)., Method: With ORLA, the person with aphasia systematically and repeatedly reads aloud sentences, first in unison and then independently. Following a no-treatment period, 25 individuals with chronic nonfluent aphasia were randomly assigned to receive 24 sessions of ORLA, 1-3 times per week, either by computer or by the SLP., Results: For participants receiving computer ORLA, change made on the Western Aphasia Battery Aphasia Quotient (WAB-AQ) during the treatment phase was larger than the change made during the no-treatment phase. Positive effect sizes for change during treatment compared with change during the no-treatment phase were obtained and were benchmarked as medium or large for the WAB-AQ and discourse measures. There was no significant difference between outcomes for computer ORLA compared with SLP-ORLA., Conclusion: Low-intensity ORLA, delivered by computer to individuals with chronic nonfluent aphasia, is efficacious and may be equivalent to ORLA delivered by an SLP.

Background and Purpose: This study evaluated the safety and feasibility of targeted epidural cortical stimulation delivered concurrently with intensive speech-language therapy for treatment of chronic non-fluent aphasia., Methods: Eight stroke survivors with non-fluent aphasia received intensive behavioural therapy for 3 h daily for 6 weeks using a combination of articulation drills, oral reading and conversational practice. Four of these participants (investigational participants) also underwent functional MRI guided surgical implantation of an epidural stimulation device which was activated only during therapy sessions. Behavioural data were collected before treatment, immediately after treatment and at 6 and 12 weeks following termination of therapy. Imaging data were collected before and after treatment., Results: Investigational participants showed a mean Aphasia Quotient change of 8.0 points immediately post-therapy and at the 6 week follow-up, and 12.3 points at 12 weeks. The control group had changes of 4.6, 5.5 and 3.6 points, respectively. Similar changes were noted on subjective caregiver ratings. Functional imaging suggested increased consolidation of activity in interventional participants., Conclusions: Behavioural speech-language therapy improves non-fluent aphasia, independent of cortical stimulation. However, epidural stimulation of the ipsilesional premotor cortex may augment this effect, with the largest effects after completion of therapy. The neural mechanisms underlying these effects are manifested in the brain by decreases in the volume of activity globally and in particular regions. Although the number of participants enrolled in this trial precludes definitive conclusions, targeted epidural cortical stimulation appears safe and may be a feasible adjunctive treatment for non-fluent aphasia, particularly when the aphasia is more severe.

Purpose: This study examined the content of 100 short scripts, co-constructed by persons with aphasia (PWA) and a clinician. The PWA subsequently learned the scripts by interacting with a computerized virtual therapist. The goal was to provide clinicians with ideas regarding content for treatment that is meaningful to PWAs., Method: Thirty-three PWAs generated the scripts, typically including 1 monologue and 2 dialogues in which the PWA was either the initiator or the responder. Scripts were analyzed for common topics and themes., Results: Thirty topics were identified and categorized into 10 themes. For the monologues, the largest category was personal stories (68%), with 12 of the 19 addressing their stroke and aphasia. For the dialogues, conversations with family were dominant (21%), followed by seeking or providing information (18%), and discussion of outside interests (14%)., Conclusion: PWAs choose to speak about their life experiences, choose to reconnect with their families, and tend to focus on communication that can help them to negotiate mundane normal life. Independent of how this content is used in treatment, materials should emphasize matters of high personal relevance to those treated.

Communication confidence is a construct that has not been explored in the aphasia literature. Recently, national and international organizations have endorsed broader assessment methods that address quality of life and include participation, activity, and impairment domains as well as psychosocial areas. Individuals with aphasia encounter difficulties in all these areas on a daily basis in living with a communication disorder. Improvements are often reflected in narratives that are not typically included in standard assessments. This article illustrates how a new instrument measuring communication confidence might fit into a broad assessment framework and discusses the interaction of communication confidence, autonomy, and self-determination for individuals living with aphasia.

This position paper, prepared by the Communication Sciences and Disorders Clinical Trails Research Group, describes communication and swallowing disorders associated with blast injuries and delineates the roles of speech-language pathologists (SLPs) and audiologists in the management of these deficits. Recovery of individuals with mild, moderate, or severe swallowing, speech, hearing, and cognitive-communication impairments is best facilitated by a team of multidisciplinary specialists including SLPs and audiologists. Speech-language pathologists and audiologists have the knowledge and skills to evaluate, treat, and research swallowing, speech, hearing, and cognitive-communication functions, and they should have a primary role in determining the clinical management of, research agenda for, and public health policies regarding individuals with blast-related head injuries from the time of injury to their return to maximized life participation and quality of life.

This study examined the efficacy of a treatment, Oral Reading for Language in Aphasia (ORLA), for individuals with chronic nonfluent aphasia of varying severity levels. With ORLA, the person with aphasia systematically and repeatedly reads sentences aloud, first in unison with the clinician and then independently. Following a period of no treatment, 25 individuals with chronic nonfluent aphasia received 24 sessions of ORLA, 1 to 3 times per week. A small, but significant mean change in the Western Aphasia Battery (WAB) Aphasia Quotient (AQ) was obtained from pre- to post-treatment. When subjects were divided by severity, medium effect sizes were obtained for all severity levels from pre- to post-treatment for the WAB AQ. Medium effect sizes were obtained for the severe aphasia group on the WAB reading subtests only, for the moderate aphasia group on the discourse measures only, and for the mild to moderate aphasia group on both the discourse and WAB writing subtests. Although more intensive therapy is preferred, individuals with chronic nonfluent aphasia may improve their language skills with low-intensity ORLA treatment, and differences in modality-specific outcomes may be anticipated based on the severity of the aphasia., (Thieme Medical Publishers.)

Purpose: This article describes three individuals with aphasia and concomitant cognitive deficits who used state-of-theart computer software for training conversational scripts., Method: Participants were assessed before and after 9 weeks of a computer script training program. For each participant, three individualized scripts were developed, recorded on the software, and practiced sequentially at home. Weekly meetings with the speech-language pathologist occurred to monitor practice and assess progress. Baseline and posttreatment scripts were audiotaped, transcribed, and compared to the target scripts for content, grammatical productivity, and rate of production of script-related words. Interviews were conducted at the conclusion of treatment., Results: There was great variability in improvements across scripts, with two participants improving on two of their three scripts in measures of content, grammatical productivity, and rate of production of scriptrelated words. One participant gained more than 5 points on the Aphasia Quotient of the Western Aphasia Battery. Five positive themes were consistently identified from exit interviews: increased verbal communication, improvements in other modalities and situations, communication changes noticed by others, increased confidence, and satisfaction with the software., Conclusion: Computer-based script training potentially may be an effective intervention for persons with chronic aphasia and concomitant cognitive deficits.

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

A growing literature suggests that with intensive treatment, individuals with chronic aphasia continue to demonstrate language recovery for years post stroke. For example, Bhogal and colleagues conducted a literature review which suggests that intensive speech language therapy delivered over a short period of time (average of 8.8 hours per week for 11.2 weeks) resulted in significant improvements, while lower-intensity therapy provided over a longer period of time (average of 2 hours per week over 22.9 weeks) did not result in positive change (Bhogal, Teasell, Speechley, & Albert, 2003). Similarly, the constraint induced aphasia therapy data emphasize the importance of massed-practice in the improvement of language skills of individuals with chronic aphasia (Pulvermuller et al., 2001; Maher et al., 2006). However, providing intensive treatment to individuals with chronic aphasia can be costly, and the current healthcare environment in the United States is one which does not recognize its value. As a result, clinicians and researchers in the field are left searching for cost effective ways to deliver aphasia treatment. One method of providing less costly but intensive treatment is via the computer.

Purpose: This article describes computer software that was developed specifically for training conversational scripts and illustrates its use with 3 individuals with aphasia., Method: Three participants with chronic aphasia (Broca's, Wernicke's, and anomic) were assessed before and after 9 weeks of a computer script training program. For each participant, 3 individualized scripts were developed, recorded on the software, and practiced sequentially at home. Weekly meetings with the speech-language pathologist occurred to monitor practice and assess progress. Baseline and posttreatment scripts were audiotaped, transcribed, and compared to the target scripts for content, grammatical productivity, and rate of production of script-related words. Interviews with the person with aphasia and his or her significant other were conducted at the conclusion of treatment., Results: All measures (content, grammatical productivity, and rate of production of script-related words) improved for each participant on every script. Two participants gained more than 5 points on the Aphasia Quotient of the Western Aphasia Battery. Five positive themes were consistently identified from the exit interviews-increased verbal communication, improvements in other modalities and situations, communication changes noticed by others, increased confidence, and satisfaction with the software., Conclusion: Computer-based script training potentially may be an effective intervention for persons with chronic aphasia.

Method: This study examines group and individual performance on word list recall and recognition in 52 patients with unilateral right hemisphere stroke., Results: On the California Verbal Learning Test, List A, Trials 1-5, patients achieved a mean score of 30.31 (SD = 13.94), which is below the mean standard score of 50 (SD = 10) in a normal population. Patients demonstrated below-average performance on other immediate and delayed recall trials and on free- and cued-recall tasks. 67% of patients showed improved performance across learning trials., Conclusion: Results provide support for encoding deficits with reduced rate of learning and inconsistent recall across trials.

Purpose: This longitudinal study examines performance of individuals with right hemisphere damage (RHD) on the California Verbal Learning Test (CVLT)., Method: 18 participants were administered the CVLT during the acute phase (<3 months post onset) and then at subsequent times up to 2 years post onset., Results: Using List A, Trials 1-5, as a global measure of learning, participants at first testing demonstrated recall skills below the mean standard score of 50 (M = 32.56, SD = 13.90). There was significant improvement between initial and second testing (t = -2.92, p = .01). Changes between second and third testing and third and fourth testing were not significant.

The complex process of cortical reorganization of language-related brain regions during recovery from aphasia and the effects of therapeutic interventions on brain systems are poorly understood. We studied two patients with chronic aphasia and compared their functional neuroanatomical responses to a younger control group on two tasks, an oral-reading task involving overt speech and a "passive" audiovisual story-comprehension task. Following identical therapy, we re-examined behavioral (language) and functional neuroanatomical changes using the same functional magnetic resonance imaging (fMRI) tasks. We hypothesized that better recovery would be associated with brain activation patterns more closely resembling healthy controls, whereas positive responses to language treatment would be associated with increased activity in undamaged left perisylvian areas and/or right-hemisphere areas homologous to the damaged regions. For the participant with a frontal lesion who was most responsive to therapy, brain activation increased in the right hemisphere during oral-reading, but decreased bilaterally in most regions on story-comprehension. The other participant with a temporal-parietal lesion showed decreased activation, particularly in the right hemisphere, during oral-reading but increased activation bilaterally on story-comprehension. Results highlight individual variability following language therapy, with brain activation changes depending on lesion site and size, language skill, type of intervention, and the nature of the fMRI task.

The management of patients with right hemisphere damage (RHD) presents a challenge to the allied health clinician. In addition to impairments in specific cognitive areas, some patients may not be aware of the presence or extent of their deficits or the impact of these deficits on everyday activities. This article briefly describes two related models of awareness/unawareness that may help guide the assessment and treatment process in patients with neurological damage including RHD. Then, some clinical care decisions regarding patients with decreased awareness are presented together with a framework for organizing and evaluating the various factors associated with a case.

Alexia is an acquired disturbance in reading. Alexias that occur after left hemisphere damage typically result from linguistic deficits and may occur as isolated symptoms or as part of an aphasia syndrome. This article presents an overview of the classification of the alexias, including both the traditional neuroanatomical perspective and the more recent psycholinguistic approach. Then, assessment procedures are reviewed, followed by a summary of treatment approaches for alexia. Finally, two case studies illustrate how oral reading of connected language (sentences and paragraphs rather than single words) has been used as a technique for treating alexia in patients with aphasia.

Purpose: This preliminary study assessed the efficacy of two treatment methods for persistent unilateral or hemispatial neglect following right hemisphere stroke., Method: Two patients received an intervention focusing on the underlying impairment of attention during visual scanning. Two other participants received an intervention that provided repetitive practice during a functional task of oral reading. Standardized tests of attention and neglect were administered before and after treatment. Performance on a functional task assessing generalization of treatment was probed at every session., Results: Results indicate no clear conclusions regarding the efficacy of either approach. Factors contributing to these equivocal findings are addressed.

Unilateral visual neglect occurs frequently after right-hemisphere stroke. This longitudinal study assessed the performance pattern of 54 individuals with unilateral right-hemisphere stroke on the Behavioural Inattention Test (BIT), a measure of unilateral neglect. Eighteen subjects returned for retesting between 6-26 months post-onset. Results confirmed the frequent occurrence of unilateral visual neglect in patients with right-hemisphere damage. A high correlation was found between the Conventional and Behavioural Subtests of the BIT, indicating that the shorter subtest may be sufficient to identify neglect. Longitudinal data revealed two subgroups, those with transient neglect that resolved within 6 months and those with neglect that persisted over time. No differences in aetiology and lesion location distinguished patients with and without neglect or patients with transient or persistent neglect. Further research is needed to confirm these results and identify other characteristics that would predict the nature of the neglect.

Objective: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke., Design: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up., Setting: Urban, acute inpatient rehabilitation facility., Patients: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan., Main Outcome Measures: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R)., Results: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing., Conclusions: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.

This article discusses the impact of cognitive-communicative and behavior problems on oral intake. Data on the swallowing outcomes of a group of patients in an acute rehabilitation facility are presented. These data illustrate the relationships among severity of dysphagia, admission and discharge Functional Independence Measure (FIM) scores, admission and discharge cognitive FIM scores and length of stay. Two case studies that describe the effect of cognitive-communicative disorders on dysphagia are provided.

Foreign accent syndrome occurs rarely after stroke. Most patients with this syndrome develop an aphasia characterized by a new accent. This report presents a 48-year-old man who sustained a left parietal hemorrhagic stroke resulting in right hemiparesis and the inability to speak. As spontaneous speech emerged several weeks later, he was noted to have a Broca's aphasia and a Dutch accent. Analysis of his speech demonstrated final consonant deletion, substitution of "d" for "th" sounds, vowel distortions, additional "uh" syllables added at the end of words, and errors in voicing. This speech pattern has persisted for more than 5 years after the stroke. Elicitation of additional history found that the patient was born in Holland and lived there until the age of 5 years, when he moved to the United States with his family. Before his stroke, he had no foreign accent. This report illustrates the importance of considering foreign accent syndrome during aphasia recovery and suggests several pathogenetic mechanisms that may contribute to the development of this syndrome.

In patients with traumatic brain injury, the anatomic and physiologic status of the swallowing mechanism may be impaired. Patients typically compensate for these impairments by learning and using compensatory strategies to ensure safe and efficient food intake. However, when cognitive-communicative and behavioral impairments are also present, the rehabilitation of dysphagia is more complex and challenging. To facilitate maximum recovery from dysphagia, an interdisciplinary team approach is essential. Teams may include several medical and allied healthcare professionals such as the physician, nurse, speech-language pathologist, clinical dietitian, and physical and occupational therapist. The psychologist may be consulted to provide expertise in behavioral management strategies. The patient and caregiver also are integral members of this treatment team. Each team member needs to be aware of the food consistencies that are appropriate and the specific feeding techniques that are required. It is critical that all team members be consistent in their approach to feeding for the patient to learn and generalize the use of compensatory strategies. This article has presented a review of the literature on swallowing problems in traumatic brain injury. It is apparent that there are relatively few data-based studies that describe the impairments and even fewer that discuss the efficacy of treatment for dysphagia in these patients. In view of the frequency of oral intake problems in individuals with traumatic brain injury, and the added challenge of the cognitive-communicative problems, further studies are needed to increase our understanding of swallowing problems, their treatment, and recovery in this patient population.

The speech-language pathologist uses a combination of direct and indirect treatment techniques to manage dysphagia in the patient with a stroke. This article reviews a variety of these procedures, including patient and family education, sensory stimulation techniques such as modifications in bolus characteristics and thermal stimulation, compensatory postures and positioning, compensatory swallowing maneuvers, and physiotherapeutic techniques. General guidelines for selection of appropriate techniques based on clinical presentation and underlying symptoms are discussed.