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Purpose: This study aimed to identify clinician-perceived barriers and facilitators before the implementation of surface electromyography (sEMG) for swallowing management, implement sEMG biofeedback in swallowing rehabilitation sessions using implementation strategies, and investigate the perceived benefits and drawbacks after the implementation of the sEMG device from the perspectives of speech-language pathologists (SLPs)., Method: An initial pre-implementation survey characterized the SLPs' practices in swallowing management regarding the use of biofeedback modalities as well as facilitators and barriers to the implementation of sEMG. In the implementation phase, six SLPs attended educational and training meetings, tested, and used sEMG with patients during their swallowing sessions. Finally, a postimplementation survey and focus group assessed the six SLPs' perceptions and experiences using sEMG and identified areas for improvement in the implementation process., Results: The majority of the 44 SLPs who answered the pre-implementation survey did not use sEMG in swallowing therapy. The most frequently reported barriers to implementation were reduced sEMG knowledge and lack of training (86.4%), lack of equipment access or availability (68.2%), and patient-related barriers (36.6%). The six SLPs who participated in the implementation phase used sEMG with 30 different patients, conducting a total of 105 sessions. They reported that it was easy to use sEMG during sessions and that sEMG helped them to teach swallowing maneuvers. Additionally, they stated that patients were motivated during sEMG sessions. Ongoing training and mentoring were some of the suggestions for implementation improvements., Conclusions: This study exemplifies the collaborative work between researchers and clinicians to facilitate the translation of technologies into clinical practice. Identifying determinants of sEMG implementation and strategies to address barriers was critical to its acceptability and adoption into clinical practice.

Purpose: Handwriting and typing have different cognitive and motor demands; however, questions remain as to whether performance in people with aphasia varies based on modality. This study compares written discourse production across handwritten and onscreen typed modalities for a large sample of people with aphasia. We also aimed to explore potential variables that predict the number of written words generated by participants and determine if modality differences emerge when these variables are included as predictors., Method: Writing samples, via handwriting and onscreen typing, elicited in a picture description task were collected from 52 participants with chronic aphasia and coded for number of words. Generalized linear mixed-effects models were used to model the data. Aphasia type, severity of aphasia, writing severity, and use of nondominant hand for writing or onscreen typing were included as predictor variables., Results: There were no significant differences between the number of words generated in the typed modality versus handwritten modality for the sample. Of the predictor variables examined, Western Aphasia Battery-Revised writing scores significantly predicted the number of words produced ( p < .001). However, the interaction of writing severity with modality was not significant., Conclusions: This preliminary study suggests that there was no effect of modality on one measure of written production, number of words. Future research is needed to evaluate if there are meaningful differences between modalities when additional measures, such as writing informativeness, are considered., Supplemental Material: https://doi.org/10.23641/asha.26506144.

Purpose: Measuring real-world communication participation of individuals with aphasia is complicated. Historically, this has been estimated through subjective participant or proxy self-report. To address potential inaccuracies, objective measures such as "talk time" have been proposed. Although promising, technological barriers to collecting and quantifying everyday conversations have been documented (e.g., background noise interference, differentiating recorded speakers, and operating Bluetooth applications). This study explored the use of a novel laryngeal sensor and a Global Positioning System (GPS) tracker with the objective of measuring mean talk time per hour and participant locations across three 8-hr days., Method: Sixteen participants utilized a wearable laryngeal sensor that captures physiological mechano-acoustic signals wirelessly, without recording speech content. The sensor differentiates speech from other laryngeal movements associated with swallowing and coughing. A GPS tracker was also issued to track daily locations. Semistructured interviews regarding feasibility and acceptability were conducted with participants at the end of the data collection period., Results: Across all participants, laryngeal sensor data were collected for a total of 38 days and GPS data for a total of 43 days, with a mean collection period of 8.21 hr ( SD = 1.38) per day. Mean talk time per hour was 56.46 s ( SD = 35.27). Participants were tracked at a mean of 2.09 locations daily (range: 1-6). Participants reported the devices were relatively comfortable to wear and easy to use., Conclusions: Preliminary findings indicated that talk time of individuals with aphasia is limited, though variable. Higher fluency ratings were related to greater mean talk time per hour and locations tracked. Results suggest wearable technology is feasible to use and acceptable to people with aphasia. In the future, wearable devices may offer innovative ways to measure communication participation., Supplemental Material: https://doi.org/10.23641/asha.26237531.

Speech-language therapy (SLT) is the most effective technique to improve language performance in persons with aphasia. However, residual language impairments remain even after intensive SLT. Recent studies suggest that combining transcranial direct current stimulation (tDCS) with SLT may improve language performance in persons with aphasia. However, our understanding of how tDCS and SLT impact brain and behavioral relation in aphasia is poorly understood. We investigated the impact of tDCS and SLT on a behavioral measure of scripted conversation and on functional connectivity assessed with multiple methods, both resting-state functional magnetic resonance imaging (rs-fMRI) and resting-state electroencephalography (rs-EEG). An individual with aphasia received 15 sessions of 20-min cathodal tDCS to the right angular gyrus concurrent with 40 min of SLT. Performance during scripted conversation was measured three times at baseline, twice immediately post-treatment, and at 4- and 8-weeks post-treatment. rs-fMRI was measured pre-and post-3-weeks of treatment. rs-EEG was measured on treatment days 1, 5, 10, and 15. Results show that both communication performance and left hemisphere functional connectivity may improve after concurrent tDCS and SLT. Results are in line with aphasia models of language recovery that posit a beneficial role of left hemisphere perilesional areas in language recovery.

Objective: To describe the trajectories of linguistic, cognitive-communicative, and health-related quality of life (HRQOL) outcomes after stroke in persons with aphasia., Design: Longitudinal observational study from inpatient rehabilitation to 18 months after stroke., Setting: Four US mid-west inpatient rehabilitation facilities (IRFs)., Participants: We plan to recruit 400 adult (older than 21 years) English speakers who meet the following inclusion criteria: (1) Diagnosis of aphasia after a left-hemisphere infarct confirmed by CT scan or magnetic resonance imaging (MRI); (2) first admission for inpatient rehabilitation due to a neurologic event; and (3) sufficient cognitive capacity to provide informed consent and participate in testing. Exclusion criteria include any neurologic condition other than stroke that could affect language, cognition or speech, such as Parkinson's disease, Alzheimer's disease, traumatic brain injury, or the presence of right-hemisphere lesions., Interventions: Not applicable., Main Outcome Measures: Subjects are administered a test battery of linguistic, cognitive-communicative, and HRQOL measures. Linguistic measures include the Western Aphasia Battery-Revised and the Apraxia of Speech Rating Scale. Cognitive-communicative measures include the Communication Participation Item Bank, Connor's Continuous Performance Test-3, the Communication Confidence Rating Scale for Aphasia, the Communication Effectiveness Index, the Neurological Quality of Life measurement system (Neuro-QoL) Communication short form, and the Neuro-QoL Cognitive Function short form. HRQOL measures include the 39-item Stroke & Aphasia Quality of Life Scale, Neuro-QoL Fatigue, Sleep Disturbance, Depression, Ability to Participate in Social Roles & Activities, and Satisfaction with Social Roles & Activities tests, and the Patient-Reported Outcome Measurement and Information System 10-item Global Health short form. The test battery is administered initially during inpatient rehabilitation, and at 3-, 6-, 12-, and 18-months post-IRF discharge. Biomarker samples are collected via saliva samples at admission and a subgroup of participants also undergo resting state fMRI scans., Results: Not applicable., Conclusions: This longitudinal observational study will develop trajectory models for recovery of clinically relevant linguistic, cognitive-communicative, and quality of life outcomes over 18 months after inpatient rehabilitation. Models will identify individual differences in the patterns of recovery based on variations in personal, genetic, imaging, and therapy characteristics. The resulting models will provide an unparalleled representation of recovery from aphasia resulting from stroke. This improved understanding of recovery will enable clinicians to better tailor and plan rehabilitation therapies to individual patient's needs., (© 2024 The Authors.)

Control comparator selection is a critical trial design issue. Preclinical and clinical investigators who are doing trials of stroke recovery and rehabilitation interventions must carefully consider the appropriateness and relevance of their chosen control comparator as the benefit of an experimental intervention is established relative to a comparator. Establishing a strong rationale for a selected comparator improves the integrity of the trial and validity of its findings. This Stroke Recovery and Rehabilitation Roundtable (SRRR) taskforce used a graph theory voting system to rank the importance and ease of addressing challenges during control comparator design. "Identifying appropriate type of control" was ranked easy to address and very important, "variability in usual care" was ranked hard to address and of low importance, and "understanding the content of the control and how it differs from the experimental intervention" was ranked very important but not easy to address. The CONtrol DeSIGN (CONSIGN) decision support tool was developed to address the identified challenges and enhance comparator selection, description, and reporting. CONSIGN is a web-based tool inclusive of seven steps that guide the user through control comparator design. The tool was refined through multiple rounds of pilot testing that included more than 130 people working in neurorehabilitation research. Four hypothetical exemplar trials, which span preclinical, mood, aphasia, and motor recovery, demonstrate how the tool can be applied in practice. Six consensus recommendations are defined that span research domains, professional disciplines, and international borders., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Conversation analysis (CA) is an established method that has been used to understand how aphasia impacts the conversational success of individuals with aphasia (IWAs) and their conversation partners. This article demonstrates CA as a valuable analytic tool for studying text messaging in aphasia to better understand the specific co-constructed actions of IWAs and their partners as they engage in this communication modality., Method: CA was applied to transcribed text message data from eight IWAs. Conversational structures present in face-to-face interactions were identified, segmented, and explicated with a focus on how IWAs and their partners negotiate interaction in this medium., Results: Three key elements of CA, namely, sequential organization, repair, and topic negotiation, were identified within the texting exchanges of participants and their texting partners and compared with existing CA studies on electronic messaging in adults without brain injury., Conclusions: Findings suggest a multitude of strategies that IWAs and their partners used to meet both transactional and interactional goals of communication. Understanding gained from applying CA to texting in aphasia can inform the development of interventions that improve access to digital communication for IWAs.

Objective: To examine associations between social participation, fatigue, and aphasia severity using patient-reported outcome measures and to examine associations between demographic/diagnostic variables and fatigue in people with aphasia., Design: Retrospective analysis of patient-reported outcome measures using a Bayesian framework., Setting: Urban rehabilitation research hospital., Participants: 67 participants (N=67) with chronic aphasia (mean age=54.1 years) as a consequence of stroke., Interventions: Not applicable., Main Outcome Measures: Ability to Participate in Social Roles and Activities, Fatigue, and Global Health Questionnaire scales from the Patient-Reported Outcomes Measurement Information System initiative and the Western Aphasia Battery-Revised. We hypothesized an association between social participation and fatigue in people with aphasia., Results: People with aphasia with higher fatigue levels tended to report less social participation. Also, people with aphasia who were a longer time post-stroke tended to report higher social participation. People with aphasia who reported better physical health were more likely to report higher social participation., Conclusions: There is an association between fatigue and social participation in people with aphasia. Fatigue should be considered in clinical assessments and treatments for this population., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice., Method: MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios., Results: The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation., Conclusion: This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Evidence-based recommendations for a core outcome set (COS; minimum set of outcomes) for aphasia treatment research have been developed (the Research Outcome Measurement in Aphasia-ROMA, COS). Five recommended core outcome constructs: communication, language, quality of life, emotional well-being and patient-reported satisfaction/impact of treatment, were identified through three international consensus studies. Constructs were paired with outcome measurement instruments (OMIs) during an international consensus meeting (ROMA-1). Before the current study (ROMA-2), agreement had not been reached on OMIs for the constructs of communication or patient-reported satisfaction/impact of treatment., Aim: To establish consensus on a communication OMI for inclusion in the ROMA COS., Methods & Procedures: Research methods were based on recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) Initiative. Participants with expertise in design and conduct of aphasia trials, measurement instrument development/testing and/or communication outcome measurement were recruited through an open call. Before the consensus meeting, participants agreed on a definition of communication, identified appropriate OMIs, extracted their measurement properties and established criteria for their quality assessment. During the consensus meeting they short-listed OMIs and participants without conflicts of interest voted on the two most highly ranked instruments. Consensus was defined a priori as agreement by ≥ 70% of participants., Outcomes & Results: In total, 40 researchers from nine countries participated in ROMA-2 (including four facilitators and three-panel members who participated in pre-meeting activities only). A total of 20 OMIs were identified and evaluated. Eight short-listed communication measures were further evaluated for their measurement properties and ranked. Participants in the consensus meeting (n = 33) who did not have conflicts of interest (n = 29) voted on the top two ranked OMIs: The Scenario Test (TST) and the Communication Activities of Daily Living-3 (CADL-3). TST received 72% (n = 21) of 'yes' votes and the CADL-3 received 28% (n = 8) of 'yes' votes., Conclusions & Implications: Consensus was achieved that TST was the preferred communication OMI for inclusion in the ROMA COS. It is currently available in the original Dutch version and has been adapted into English, German and Greek. Further consideration must be given to the best way to measure communication in people with mild aphasia. Development of a patient-reported measure for satisfaction with/impact of treatment and multilingual versions of all OMIs of the COS is still required. Implementation of the ROMA COS would improve research outcome measurement and the quality, relevance, transparency, replicability and efficiency of aphasia treatment research., What This Paper Adds: What is already known on this subject International consensus has been reached on five core constructs to be routinely measured in aphasia treatment studies. International consensus has also been established for OMIs for the three constructs of language, quality of life and emotional well-being. Before this study, OMIs for the constructs of communication and patient-reported satisfaction/impact of treatment were not established. What this paper adds to existing knowledge We gained international consensus on an OMI for the construct of communication. TST is recommended for inclusion in the ROMA COS for routine use in aphasia treatment research. What are the potential or actual clinical implications of this work? The ROMA COS recommends OMIs for a minimum set of outcomes for adults with post-stroke aphasia within phases I-IV aphasia treatment research. Although not intended for clinical use, clinicians may employ the instruments of the ROMA COS, considering the quality of their measurement properties. The systematic inclusion of a measure of communication, such as TST, in clinical practice could ultimately support the implementation of research evidence and best practices., (© 2022 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists.)

Objective: Voluntary cough testing (VCT) may be useful for determining aspiration risk in neurogenic dysphagia; however, has yet to be investigated in traumatic cervical spinal cord injury (tCSCI). The study explored if VCT may elucidate swallowing safety and kinematics related to airway protection in tCSCI survivors., Methods: Ten inpatients, 13-73 days post-tCSCI (7 incomplete injuries), completed VCT and a modified barium swallowing study that was analyzed via the Penetration Aspiration Scale (PAS) and norm-referenced measures of swallowing events related to airway protection. Spearman rho correlations explored relations among cough airflow, median PAS, and airway protection. Mann-Whitney U tests explored group differences based on clinical airway invasion (PAS > 2) and receiver operating characteristic statistics probed the sensitivity/specificity of VCT measures., Results: Safe (PAS > 2) and unsafe swallowers differed by cough volume acceleration (CVA) for the total sample and by inspiratory duration for incomplete injuries (p = 0.03, r > 0.7). A cut-off value of 24.8 L/s for CVA predicted airway invasion (AUC = 0.917, p = 0.03) with sensitivity = 100%/specificity = 75%. CVA correlated with delayed laryngeal vestibule closure during swallowing for both the total sample and for incomplete injuries (r s  > 0.6, p < 0.05). Blunted peak flow and prolonged cough phases were associated with disordered laryngeal kinematics and prolonged bolus transit during swallowing (p < 0.05)., Conclusions: Reduced CVA, blunted peak flow, and prolonged cough phases reflected PAS and disrupted mechanisms of airway protection in tCSCI survivors, demonstrating promise for VCT as a clinical assessment for post-tCSCI dysphagia., Level of Evidence: 3 Laryngoscope, 133:1434-1441, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Individuals with aphasia may have impairments in cognition, higher incidences of depression, and a variety of post-stroke functional impairments. However, evaluating these issues is challenging since most assessments require some degree of linguistic processing and task instructions are often verbal. Heart rate variability has shown to be an objective marker for cognitive functioning in neurologically healthy individuals, depression and post-stroke depression, and post-stroke functional impairments. However, before the utility of heart rate variability is established in persons with aphasia, its test-retest reliability needs to be established. The purpose of this study was to assess test-retest reliability of heart rate variability metrics in persons with aphasia. Heart rate variability was recorded at rest while in a sitting position in twenty-one persons with aphasia at two time points. Heart rate variability metrics were mostly moderately reliable. The majority of participants had resting heart rate variability parasympathetic and sympathetic indexes similar to those of neurologically healthy individuals. Further research is needed to establish the test-retest reliability of heart rate variability metrics in different postures and breathing conditions in persons with aphasia.

Background: Post-stroke depressive symptoms are prevalent and impairing, and elucidating their course and risk factors is critical for reducing their public health burden. Previous studies have examined the course of post-stroke depression, but distinct depressive symptom dimensions (eg, somatic symptoms, negative affect [eg, sadness], anhedonia [eg, loss of interest]) may vary differently over time., Objective: The present study examined within-person and between-person associations between depressive symptom dimensions across 3 timepoints in the year following discharge from in-patient rehabilitation hospitals, as well as the impact of multiple clinical variables (eg, aphasia)., Methods: Stroke survivors completed the Center for Epidemiologic Depression Scale (CES-D) at discharge from post-stroke rehabilitation ("T1") and at 3-month ("T2") and 12-month ("T3") follow-ups. Scores on previously identified CES-D subscales (somatic symptoms, anhedonia, and negative affect) were calculated at each timepoint. Random intercept cross-lagged panel model analysis examined associations between symptom dimensions while disaggregating within-person and between-person effects., Results: There were reciprocal, within-person associations between somatic symptoms and anhedonia from T1 to T2 and from T2 to T3. Neither dimension was predictive of, or predicted by negative affect., Conclusions: The reciprocal associations between somatic symptoms and anhedonia may reflect a "vicious cycle," and suggest these 2 symptom dimensions may be useful indicators of risk and/or intervention targets. Regularly assessing depression symptoms starting during inpatient rehabilitation may help identify stroke survivors at risk for depression symptoms and facilitate early intervention.

Videofluoroscopic analyses of swallowing in survivors of traumatic cervical spinal cord injury (tCSCI) have been largely limited to case reports/series and qualitative observations. To elucidate the disrupted physiology specifically underlying dysphagia post-tCSCI, this prospective observational study analyzed videofluoroscopic swallow studies (recorded at 30 frames per second) across 20 tCSCI survivors. Norm-referenced measures of swallow timing or displacement, and calibrated area measures of laryngeal vestibule closure (LVC) were explored in relation to the severity of aspiration or pharyngeal residue. Videofluoroscopic performance was compared by injury level, surgical intervention, tracheostomy status, and in relation to clinical bedside assessments. Reduced pharyngeal constriction, delayed hyoid elevation, and impaired LVC characterized post-tCSCI dysphagia. Reduced extent of hyoid excursion and of pharyngoesophageal segment (PES) opening were not as prominent, only present in approximately half or less of the sample. Ten participants aspirated and 94% of aspiration events were silent. Severity of aspiration significantly correlated with pharyngeal constriction and prolonged pharyngeal transit times. Post-swallow residue correlated with delayed PES distention/closure and prolonged pharyngeal transit. Clinical inference regarding the integrity of the pharyngeal phase at bedside was limited; however, EAT-10 scores demonstrated promise as an adjuvant clinical marker of post-tCSCI dysphagia. This exploratory study further describes the pathophysiology underlying post-tCSCI dysphagia to promote deficit-specific rehabilitation and functional recovery., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: It is known that interpreter-mediated aphasia assessments may not provide the linguistic information that speech-language pathologists (SLPs) need to provide accurate diagnoses and determine treatment goals. The purpose of our study was to understand the perceptions of SLPs and interpreters who collaborate in a medical setting and to develop a checklist to categorize and quantify the errors interpreters make. Interpreter training may lead to unintentional errors that impact the information the SLP gains from the assessment session., Method: In Phase 1 of the study, 38 hospital SLPs and 26 interpreters responded to survey questions about their experiences working with the other discipline. In Phase 2, eight Spanish-speaking interpreters and two Spanish-speaking participants with fluent aphasia took part in a standardized interpreter-mediated aphasia assessment. A bilingual SLP and a Spanish-speaking interpreter analyzed and coded the assessments for errors in the interpreters' behaviors., Results: Results from the survey demonstrated that both SLPs and interpreters would like the interpreters to have more education regarding the diagnosis of aphasia and an understanding of the SLP's goals during an aphasia assessment. A lack of time was considered the primary hindrance to educating interpreters during an evaluation session. The checklist included interpreter behaviors that could significantly impact the SLP's ability to diagnose aphasia: omission of speech/language information, meaning errors, and cueing. Positive behaviors noted were calling attention to patient error and pointing out potential confusing items., Conclusions: Education for both disciplines will enhance the accuracy of interpreter-mediated aphasia assessments. A checklist tool with specific examples of errors may be useful in educating not only experienced interpreters and SLPs but also students in both disciplines.

Purpose: Text messaging is a pervasive form of communication in today's digital society. Our prior research indicates that individuals with aphasia text, but they vary widely in how actively they engage in texting, the types of messages they send, and the number of contacts with whom they text. It is reported that people with aphasia experience difficulties with texting; however, the degree to which they are successful in conveying information via text message is unknown. This study describes the development of a rating scale that measures transactional success via texting and reports on the transactional success of a sample of 20 individuals with chronic aphasia. The relationships between texting transactional success and aphasia severity, texting confidence, and texting activity are explored., Method: Performance on a texting script was evaluated using a three-category rating in which turns elicited from participants with aphasia received a score of 0 ( no transaction of message ), 1 ( partial transaction ), or 2 ( successful transaction ). Internal consistency was assessed using Cronbach's alpha. Interrater reliability was determined using intraclass correlation coefficient and Krippendorff's alpha., Results: Although preliminary, results suggest adequate internal consistency and strong interrater reliability. Texting transactional success on the script response items was significantly correlated with overall aphasia severity and severity of reading and writing deficits, but there was no relationship between transactional success and texting confidence or overall texting activity., Conclusions: This study describes initial efforts to develop a rating scale of texting transactional success and to evaluate the validity of scores derived from this measure. Information from a texting transactional success measure could inform treatment that aims to improve electronic messaging in people with aphasia.

Purpose: Intensive Comprehensive Aphasia Programs (ICAPs) were first described in 2013 with an international survey documenting 12 unique programs. ICAPs involve high dose intervention delivered in both group and individual settings, targeting communication across impairment, functioning, participation, and contextual domains. In this study, we aimed to investigate international growth in ICAPs., Materials and Methods: We developed a 43-item questionnaire expanding on the original 2013 version to investigate program modifications, activities, protocolised therapies, software and apps, and family involvement. The survey was disseminated to aphasia clinicians and researchers internationally (November 2019-February 2020)., Results: Thirty-nine unique respondents completed the survey from nine countries. Twenty-one met the criteria for an ICAP or modified ICAP (mICAP): 14 ICAPs; 7 mICAPs, and 13 of these were new programs. ICAPs differed from mICAPs with greater emphasis on group sessions, use of technology, total communication, advocacy, and art activities. A large range of protocolised therapies were used across programs. An increased focus on mood and psychosocial well-being was observed compared to the 2013 survey., Conclusions: The number and comprehensiveness of ICAPs has grown since 2013 with development of modified versions. Future research should focus on comparative efficacy of ICAPs/mICAPs and other forms of aphasia interventions and factors underpinning growth and sustainability.Implications for RehabilitationClinicians who coordinate or are considering commencing an ICAP in future can use these results to consider the design of their program.Coordinators should carefully consider the components of their ICAPs and advise consumers whether they meet the definition of an ICAP or a mICAP.With the increasing number of ICAPs across the globe, clinicians commencing an ICAP may wish to contact existing ICAPs within their country for advice.Program sustainability may be challenging and these results provide an indication of some of the key challenges coordinators may face.

Background: Studies suggest that language recovery in aphasia may be improved by pairing speech-language therapy with transcranial direct current stimulation. However, results from many studies have been inconclusive regarding the impact transcranial direct current stimulation may have on language recovery in individuals with aphasia. An important factor that may impact the efficacy of transcranial direct current stimulation is its timing relative to speech-language therapy. Namely, online transcranial direct current stimulation (paired with speech-language therapy) and offline transcranial direct current stimulation (prior to or following speech-language therapy) may have differential effects on language recovery in post-stroke aphasia. Transcranial direct current stimulation provided immediately before speech-language therapy may prime the language system whereas stimulation provided immediately after speech-language therapy may aid in memory consolidation. The main aim of this study is to investigate the differential effects of offline and online transcranial direct stimulation on language recovery (i.e., conversation) in post-stroke aphasia., Methods/design: The study is a randomized, parallel-assignment, double-blind treatment study. Participants will be randomized to one of four treatment conditions and will participate in 15 treatment sessions. All groups receive speech-language therapy in the form of computer-based script practice. Three groups will receive transcranial direct current stimulation: prior to speech-language therapy, concurrent with speech-language therapy, or following speech-language therapy. One group will receive sham stimulation (speech-language therapy only). We aim to include 12 participants per group (48 total). We will use fMRI-guided neuronavigation to determine placement of transcranial direct stimulation electrodes on participants' left angular gyrus. Participants will be assessed blindly at baseline, immediately post-treatment, and at 4 weeks and 8 weeks following treatment. The primary outcome measure is change in the rate and accuracy of the trained conversation script from baseline to post-treatment., Discussion: Results from this study will aid in determining the optimum timing to combine transcranial direct current stimulation with speech-language therapy to facilitate better language outcomes for individuals with aphasia. In addition, effect sizes derived from this study may also inform larger clinical trials investigating the impact of transcranial direct current stimulation on functional communication in individuals with aphasia., Trial Registration: ClinicalTrials.gov NCT03773406. December 12, 2018., (© 2022. The Author(s).)

Objective: To identify and measure the costs of implementing an intensive comprehensive aphasia program (ICAP)., Design: Retrospective cost analysis of a clinical ICAP. Cost inputs were gathered directly from the provider of the ICAP. We performed several sensitivity analyses to examine major cost drivers and to separate start-up costs from operating costs., Setting: Urban rehabilitation hospital., Participants: Adults with aphasia., Main Outcome Measures: Total implementation cost to the provider., Results: Implementation cost of running the ICAP for the first time was $133,644 for a cohort of 8 participants with aphasia. Break-even charges per participant ranged from $15,278 for 10 participants to $19,700 for 6 participants. After accounting for start-up costs and efficiencies gained, the fourth and subsequent programs were estimated to cost $84,855 each. The majority of the costs were personnel costs, and the cost of the speech language pathologist's time was the main cost driver in this analysis., Conclusions: Initial implementation costs are high compared with subsequent programs. Future work should examine effectiveness of an ICAP compared with other treatments to determine its cost-effectiveness., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the effect of complexity and feedback on script training outcomes in aphasia DESIGN: Randomized balanced single-blind 2 × 2 factorial design., Setting: Freestanding urban rehabilitation hospital., Participants: Adults with fluent and nonfluent aphasia (at least 6 months post onset)., Interventions: Experimental treatment was AphasiaScripts, a computer-based script training program. Scripts were 10-turns long and developed at different complexity levels to allow for comparison of high vs low complexity. The program was modified to contrast high vs low feedback conditions during sentence practice. Participants were instructed to practice three 30-minute sessions per day, 6 days per week for 3 weeks., Main Outcome Measures: Gains achieved from baseline in accuracy and rate of production of trained and untrained script sentences at post treatment and at 3-, 6-, and 12-weeks after the end of treatment., Results: Sixteen participants completed the intervention. On the trained script, gains were statistically significant for both accuracy and words per minute at post treatment and 3-, 6-, and 12-week maintenance. Gains on the untrained script were smaller than on the trained script; they were statistically significant only for accuracy at post treatment and 3-week maintenance. Complexity had an influence on accuracy at post-treatment (F 1 =4.8391, P=.0501) and at maintenance (F 1 =5.3391, P=.0413). Practicing scripts with high complexity increased accuracy by 11.33% at post treatment and by 9.90% at maintenance compared with scripts with low complexity. Participants with nonfluent aphasia made greater gains than those with fluent aphasia. There was no significant effect of feedback., Conclusions: This study reinforces script training as a treatment option for aphasia. Results highlight the use of more complex scripts to better promote acquisition and maintenance of script production skills. There is a need for further investigation of these variables with larger samples and with other types of aphasia treatments., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Computer-based interventions for persons with traumatic brain injury (TBI) are a rapidly developing treatment modality. However, the usability and acceptability of such treatments have not been thoroughly studied. We describe the user-experience of a computerized intervention in persons with TBI called the Work-Related Communication (WoRC) program. Two coders used qualitative analysis of semi-structured interviews to complete a thematic content analysis along with a cost-benefit analysis. Ten participants with severe TBI more than 1-year postinjury were interviewed. Seven participants were male, and three were female. Their mean age was 41.6 years (standard deviation: 13.1). All had 4 years of college or less and experienced severe TBIs. A qualitative analysis of the WoRC program usability resulted in the categories of Content (aspects of treatment approach), Interface (aspects of presentation), and Abilities (aspects of the cognitive disorder). WoRC program acceptability categories emerged as Specific (trained strategies can be applied to specific scenarios) and Personal (individual factors related to willingness to implement the trained strategies). The cost-benefit analysis demonstrated a 50.2% reduction in treatment costs, indicating that computer-enhanced interventions are a potentially cost-effective way to increase behavioral outcomes. We discuss these findings as they relate to future development of computer-enhanced programs for persons with TBI., Competing Interests: The authors have no conflicts of interest to report., (Thieme. All rights reserved.)

There are many different approaches to the rehabilitation of patients with aphasia, a communication disorder that affects a person's understanding and expression of spoken and written language. One approach called "functional communication interventions" aims to enhance communication success as opposed to solely improving linguistic abilities. This approach encompasses many skills (eg, gesturing) and factors (eg, access to communication supports) that support sending and receiving messages in "real-world" daily activities and environments. Functional communication treatments are highly diverse and not always well described. A framework that may provide structure to the description of functional communication interventions for aphasia is the Rehabilitation Treatment Specification System (RTSS). The RTSS was developed by an interdisciplinary research team to describe interventions across any rehabilitation discipline and in any setting or format. The RTSS uses a common language and a systematic approach to describing treatment and includes 3 connected elements-a single target, 1 or more ingredients, and a mechanism of action-that, taken together, attempt to explain how and why a treatment works. Although the RTTS has been described previously within the field of speech-language pathology, it has not yet been applied to the field of aphasiology. We applied the RTSS framework to a sample of peer-reviewed studies that represent functional communication treatments, including Promoting Aphasics' Communicative Effectiveness (PACE), modified Response Elaboration Training (M-RET), script training, conversation treatment, and communication partner training. We discuss both the advantages and disadvantages of using the RTSS framework to better understand the important elements of functional communication treatment approaches for aphasia., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate articles in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate dysphagia in patients recovering from SARS-CoV-2 admitted to acute inpatient rehabilitation by summarizing clinical swallow evaluation and videofluoroscopic swallow study findings., Design: Retrospective cohort study., Setting: Urban inpatient rehabilitation hospital., Participants: The first inpatients admitted with SARS-CoV-2 (N=40) who participated in a videofluoroscopic swallow study., Interventions: Not applicable., Main Outcome Measures: Patient characteristics upon admission (duration of intubation, tracheostomy status, comorbidities, videofluoroscopic swallow study (VFSS) completion at previous level of care); admission International Dysphagia Diet level (IDDSI); Mann Assessment of Swallowing Ability (MASA), Functional Oral Intake Scale (FOIS), dysphagia severity rating; penetration aspiration scale (PAS) rated during VFSS; and IDDSI level recommended after completion of VFSS., Results: Twenty percent of patients had been evaluated by videofluoroscopy in acute care. Nineteen of 37 (51%) individuals were upgraded to IDDSI level 7 regular diet with level 0 thin liquids and achieved a FOIS of 7 after the completion of the VFSS. Five individuals (13%) received a diet downgrade or remained on the same diet recommendations from their admission. Total numerical score (TNS) of less than 170 on the MASA predicted presence of aspiration in 27% of patients (6 of 22). Seventy-two percent of the sample (16 of 22) had a TNS less than 170 but did not demonstrate any instances of aspiration. The odds of patients having a PAS of 3 or greater increased by approximately 15% (odds ratio, 1.15; 95% confidence interval, 1.03-1.27; P=.013). Thus, with each additional day of intubation during acute care stay, there was a 15% greater likelihood of having airway invasion., Conclusions: Instrumental swallow evaluations are imperative to diagnose and treat dysphagia in the post-coronavirus disease population. Because of the heterogeneity of this population, high incidence of prolonged intubation, and limitations of the clinical swallowing evaluation, instrumental assessments need to be performed on a more consistent basis as infection prevention protocols evolve., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: In today's digital world, text messaging is one of the most widely used ways that people stay connected. Although it is reported that people with aphasia experience difficulties with texting, little information is available about how they actually do text. This study reports texting behaviors, such as the number and type of messages sent and contacts individuals with aphasia have. The relationships between texting behaviors and aphasia severity, including writing impairments, and social connectedness are explored., Method: Twenty participants were sampled from an ongoing randomized clinical trial investigating an electronic writing treatment for aphasia (Clinical Trials Identifier: NCT03773419). Participants provided consent for researchers to view and analyze texts sent and received over a 7-day period immediately prior to the assessment. Participants' text messages were recorded, transcribed verbatim, and coded., Results: Over the 7-day period, the number of contacts with whom participants texted ranged from one to 18. The mean number of text messages exchanged was 40.3 ( SD = 48.24), with participants sending an average of 15.4 ( SD = 23.45) texts and receiving an average of 24.9 ( SD = 29.44) texts. Participants varied in the types of texts sent; some had a larger proportion of initiated texts, while others drafted more responses, either simple or elaborative in nature. There was no correlation between the total number of texting exchanges and the Western Aphasia Battery-Revised Aphasia Quotient ( r s = .13, p = . 29) or the Western Aphasia Battery-Revised Writing subtest ( r s = .05, p = .42). There was also no correlation between the total number of texting exchanges and scores on measures of social connectedness., Conclusions: Texting behaviors of individuals with aphasia are widely variable. Demographics, severity of aphasia and writing, and social connectedness may not predict texting behaviors. Therefore, it is clinically important to explore the unique texting abilities and preferences of each individual to meet their communication and social participation goals. Supplemental Material https://doi.org/10.23641/asha.14669664.

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Difficulty swallowing (dysphagia) occurs frequently in patients with neurological disorders and can lead to aspiration, choking, and malnutrition. Dysphagia is typically diagnosed using costly, invasive imaging procedures or subjective, qualitative bedside examinations. Wearable sensors are a promising alternative to noninvasively and objectively measure physiological signals relevant to swallowing. An ongoing challenge with this approach is consolidating these complex signals into sensitive, clinically meaningful metrics of swallowing performance. To address this gap, we propose 2 novel, digital monitoring tools to evaluate swallows using wearable sensor data and machine learning., Methods: Biometric swallowing and respiration signals from wearable, mechano-acoustic sensors were compared between patients with poststroke dysphagia and nondysphagic controls while swallowing foods and liquids of different consistencies, in accordance with the Mann Assessment of Swallowing Ability (MASA). Two machine learning approaches were developed to (1) classify the severity of impairment for each swallow, with model confidence ratings for transparent clinical decision support, and (2) compute a similarity measure of each swallow to nondysphagic performance. Task-specific models were trained using swallow kinematics and respiratory features from 505 swallows (321 from patients and 184 from controls)., Results: These models provide sensitive metrics to gauge impairment on a per-swallow basis. Both approaches demonstrate intrasubject swallow variability and patient-specific changes which were not captured by the MASA alone. Sensor measures encoding respiratory-swallow coordination were important features relating to dysphagia presence and severity. Puree swallows exhibited greater differences from controls than saliva swallows or liquid sips ( p < 0.037)., Discussion: Developing interpretable tools is critical to optimize the clinical utility of novel, sensor-based measurement techniques. The proof-of-concept models proposed here provide concrete, communicable evidence to track dysphagia recovery over time. With refined training schemes and real-world validation, these tools can be deployed to automatically measure and monitor swallowing in the clinic and community for patients across the impairment spectrum., Competing Interests: S.X. and J.A.R. hold equity in the company Sonica Health, which makes wearable sensors for medical applications. A patent on the wireless sensor and methods for medical use has been filed by Northwestern University with J.A.R., S.X., B.M-H., L.R.C., A.J., and M.K.O. as inventors. The remaining authors have no conflicts of interest to declare., (Copyright © 2021 by S. Karger AG, Basel.)

Objective: To investigate an intensive asynchronous computer-based treatment delivered remotely with clinician oversight to people with aphasia., Design: Single-blind, randomized placebo-controlled trial., Setting: Free-standing urban rehabilitation hospital., Participants: Adults with aphasia (at least six months post-onset)., Interventions: Experimental treatment was Web ORLA ® (Oral Reading for Language in Aphasia) which provides repeated choral and independent reading aloud of sentences with a virtual therapist. Placebo was a commercially available computer game. Participants were instructed to practice 90 minutes/day, six days/week for six weeks., Main Measures: Change in Language Quotient of the Western Aphasia Battery-Revised from pre-treatment to post-treatment and pre-treatment to six weeks following the end of treatment., Results: 32 participants (19 Web ORLA ® , 13 Control) completed the intervention and post-treatment assessment; 27 participants (16 Web ORLA ® , 11 Control) completed the follow-up assessment six weeks after treatment had ended. Web ORLA ® treatment resulted in significant improvements in language performance from pre-treatment to immediately post-treatment ( X  = 2.96; SD = 4.32; P  < 0.01; ES = 0.68) and from pre-treatment to six weeks following the end of treatment ( X  = 4.53; SD = 3.16; P  < 0.001; ES = 1.43). There was no significant difference in the gain from pre-treatment to post-treatment for the Web ORLA ® versus Control groups. However, the Web ORLA ® group showed significantly greater gains at the six-week follow-up than the control group ( X  = 2.70; SD = 1.01; P  = 0.013; ES = 1.92)., Conclusion: Results provide evidence for improved language outcomes following intensive, web-based delivery of ORLA ® to individuals with chronic aphasia. Findings underscore the value of combining clinician oversight with the flexibility of asynchronous practice.

Purpose Depression assessment is challenging in persons with aphasia given their language impairment. Studies have used both self-report scales and by-proxy measures of depression in persons with aphasia. However, the validity of these measures has been called into question. The aim of this study was to conduct a preliminary investigation into aspects of validity of the community version of the Stroke Aphasia Depression Questionnaire (SADQ-10) and the Center for Epidemiological Studies Depression Scale-Revised (CESD-R). Method Twenty-four participants with chronic aphasia completed the CESD-R, the Patient-Reported Outcomes Measurement Information System Global Mental Health scale (PROMIS GMH), and the Dynamic Visual Assessment of Mood Scales (D-VAMS) while their caregivers completed the SADQ-10. Internal consistency of the CESD-R and the SADQ-10 and the convergent validity of the CESD-R, SADQ-10, PROMIS GMH, and D-VAMS were examined. Results The SADQ-10 and the CESD-R were internally consistent. The CESD-R was moderately correlated with the SADQ-10, PROMIS GMH, and D-VAMS. However, the SADQ-10 was not correlated with the PROMIS GMH and D-VAMS. Conclusions We suggest both the CESD-R and the SADQ-10 be used together to screen for depression in persons with aphasia. Further studies with larger sample sizes need to be conducted to establish validity of other depression screening instruments in person with aphasia.

Objective: This proof-of-concept study presents a computer-based social communication training for spoken workplace interactions called Work-Related Communication (WoRC) training. This program implements didactic training, role-play, and immediate feedback using a simulation approach to improve spoken language performance. The unique target of this training is a category of linguistic markers called politeness markers which are essential for cooperative workplace exchanges., Methods: We recruited eight adults with chronic traumatic brain injury. All participants demonstrated reduced politeness marker use in language sampling before treatment. This study had a quasi-experimental treatment design. We measured the rate of politeness marker use (politeness markers per minute) using the Voicemail Elicitation Task and novel role-play tasks, and the La Trobe Communication Questionnaire as outcome (dependent) variables., Results: After training, participants demonstrated an increase in trained and untrained politeness marker use that was significant for the novel role-play tasks. The La Trobe Communication Questionnaire found that familiar conversation partners reported a significant increase in social communication skills., Conclusion: The WoRC program has implications for introducing a sociolinguistic foundation for social communication training in general and specifically for vocational placement., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Transcranial direct current stimulation (tDCS) may enhance speech and language treatment (SLT) for stroke survivors with aphasia; however, to date, there is no standard protocol for the application of tDCS in post-stroke aphasia. We explored the safety and efficacy of fMRI-guided tDCS on functional language and cortical activity when delivered to the lesioned left hemisphere concurrently with SLT across an extended, six-week treatment period. Twelve persons with chronic, nonfluent aphasia following a single left-hemisphere stroke participated in the three-arm (anodal vs. cathodal vs. sham) single-blind, parallel, pilot trial. No serious adverse events occurred during 30 treatment sessions or in the following six weeks. All groups demonstrated functional language gains following intensive treatment; however, active tDCS resulted in greater gains in standardized, probe, and caregiver-reported measures of functional language than sham. Evidence declaring one polarity as superior for inducing language recovery was mixed. However, cathodal stimulation to the lesioned left hemisphere, expected to have a down-regulating effect, resulted in increased areas of cortical activation across both hemispheres, and specifically perilesionally. Generalization of these preliminary findings is limited; however, results are nevertheless compelling that tDCS combined with SLT can be safely applied across extended durations, with the potential to enhance functional language and cortical activation for persons with aphasia., Competing Interests: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Background: Network analysis has been used to elucidate the relationships among depressive symptoms, but this approach has not been typically used in persons with stroke., Method: Using a sample of 835 persons with stroke from Stroke Recovery in Underserved Populations 2005-2006 dataset, this study used network analysis to (1) examine changes in relationships between depressive symptoms over time, and (2) test whether baseline network characteristics were prognostic for depression persistence. Network analysis was performed on depressive symptoms collected at discharge from inpatient rehabilitation and at 3-months and 12-months post-discharge., Results: The depressive symptom network at discharge was less connected than at both post-discharge follow-ups. Trouble focusing and feeling good as others were the most predictable symptoms at post-discharge, even though they were less connected to other depressive symptoms. Among participants with elevated baseline depression severity, those whose depression persisted 12 months later had more strongly connected networks at discharge than those who recovered 12 months later., Limitations: This study was unable to determine the directionality of edges. The depression scale was administered differently across time points., Conclusion: These results suggest that baseline network connectivity can predict the course of post-stroke depression, similar to non-stroke populations. More broadly, the study highlights the importance of examining relationships between individual depressive symptoms rather than only sum-scores., Competing Interests: Declaration of Interest: None

Background: Intensive comprehensive aphasia programs (ICAPs) have gained popularity in recent years. Outcomes from ICAPs have demonstrated measurable improvements for most who take part, but how do people with aphasia and their family members experience an ICAP?, Aim: The aim of this paper was to explore, through qualitative interviews, the experiences of persons with aphasia and their family members who took part in an ICAP., Methods & Procedures: Twelve interviews were conducted with persons with aphasia and family members regarding their experiences with the ICAP that they had just completed. Nine persons with aphasia were interviewed with their family members and three chose to take part in the interview alone. The Framework Analysis method was used to identify themes from the transcribed interviews., Outcomes & Results: The interviewees discussed four themes related to treatment, psychosocial environments, physical environments, and outcomes. The interviewees remarked on the challenges that were provided by the treatment and how the treatment was different from previous treatment. Comments were made related to the relationships the participants and families developed within the context of the program. The physical environment allowed for relationships to develop. The interviewees discussed the physical and social environment as important additional factors that contribute to the overall therapeutic effect of the ICAP. Positive outcomes were noted in language skills and psychosocial contexts., Conclusions: Based on interviewees' descriptions of this one ICAP, the concept of a therapeutic milieu was developed to describe how the intersection of the treatment, psychosocial interactions, and physical setting related to outcomes. Interviewees described how the therapeutic milieu of the ICAP was interwoven with the intensive therapy to create a "package" of therapy that led to improved outcomes. Implications for non-ICAP clinical practice is that participants linked more intensive therapy and greater social interactions with better outcomes., Competing Interests: Disclosure statement No potential conflict of interest was reported by the authors.

Clinicians must often contend with ethical issues that arise during rehabilitation. When a patient has right hemisphere damage (RHD), these concerns may be exacerbated because of the presence of cognitive deficits. In this article, we focus on the ethical principle of respect for autonomy, which raises issues relevant to patients with RHD who have impaired executive control functions. Respect for autonomy involves respecting others in terms of their decision-making and subsequent actions. Disagreements may occur between members of the rehabilitation team, the patient, and family about the decisions that the patient makes. Clinicians may have concerns about the patient's capacity to make informed decisions. Indeed, in some cases, because the patient is "talking," the verbal skills may mask the impairments in underlying cognitive processes. We provide two case examples of patients with RHD with sufficient language skills to express their choices, but cognitive deficits that affect their decision-making abilities. We use a clinical decision-making model adapted from Jonsen et al to discuss the cases. In both cases, the rehabilitation team strives to balance what they deem to be in the best interest of the patient while continuing to respect the patient's autonomy., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background . Persons with aphasia often present with low mood/depression, which can negatively affect their quality of life. The validity and reliability of existing depression measures for aphasia have been called into question. Eye tracking in nonstroke populations is reliable in identifying low mood/depression. Depressed persons are biased to negative emotions compared with nondepressed persons and have an absence of bias to positive emotions. However, nondepressed persons may be biased to positive emotions. Objective . To examine the feasibility of using eye tracking to measure mood in persons with aphasia. Methods . We recruited 22 persons with chronic aphasia and 12 healthy controls. Participants completed 2 self-report measures of mood. They also viewed faces that showed happy, sad, and neutral facial expressions during eye tracking. We analyzed 2 eye tracking indices: initial gaze orientation and gaze maintenance to happy, sad, and neutral faces. Results . For initial gaze orientation, participants with aphasia fixated faster on emotional faces compared with healthy controls but directed their gaze less often to happy faces compared with healthy controls. For gaze maintenance components, the duration of first fixation and total fixation duration were shorter on sad faces for participants with aphasia compared with healthy controls. Conclusion . Use of eye tracking with faces representing different mood states is feasible in persons with aphasia. Although there were some similarities, participants with aphasia had different gaze patterns to emotional faces compared with healthy controls. Further research is needed to establish whether this is a valid and reliable method of mood assessment.

Background : Post-stroke dysphagia is characterized by reduced corticolingual excitability and lingual pressure; however, it remains unknown if transcranial magnetic stimulation (TMS) directly facilitates lingual pressure generation. Objectives : To explore optimal procedures for single pulse TMS using neuronavigation to evoke lingual pressure in intact and disrupted neural networks. Methods : Using co-registered functional magnetic resonance imaging, stimulation sites were determined for five healthy adults ( M age = 67) and four stroke survivors with dysphagia and reduced tongue strength ( M age = 66). Evoked lingual pressures were sampled across 45-65% of maximum stimulator output. Healthy participants repeated TMS with a bite block to isolate lingual pressure from off-target stimulation of mandibular elevators. Results : Only one functionally-guided stimulation site fell within previously reported optimal lateral (8-11cm) and anterior (2-4.25cm) coordinates. Lingual pressure was stable prior to pulse and increased linearly with intensity for both groups ( p = .005). Post-stroke active motor thresholds were elevated compared to healthy adults ( p = .025). Lingual pressure latency remained stable across intensities ( p > .05). Jaw stabilization via bite block reduced the mean magnitude of evoked lingual pressure by approximately 16%. Conclusions : Single pulse TMS directly evokes higher lingual pressure and can define motor thresholds in intact and disordered corticolingual pathways. Stimulation sites using neuronavigation in healthy adults and stroke survivors largely differed from external coordinates in the literature that were predominantly established in young adults. Procedures to investigate motor thresholds for lingual pressure generation are proposed. The therapeutic role of TMS to address post-stroke deficits in lingual pressure and corticolingual excitability warrants continued investigation.

People with aphasia frequently present with nonlinguistic deficits, in addition to their compromised language abilities, which may contribute to their problems with reading comprehension. Treatment of attention, working memory and executive control may improve reading comprehension in individuals with aphasia, particularly those with mild reading problems. This single-case experimental design study evaluated the efficacy of Attention Process Training-3, an intervention combining direct attention training and metacognitive facilitation, for improving reading comprehension in individuals with mild aphasia. A multiple baseline design across six participants was used to evaluate treatment effects. The primary outcome measure was a maze reading task. Cognitive measures were administered pre- and post-treatment. Visual inspection of graphed maze reading performance data indicated a basic effect between APT-3 and improved maze reading for three of the six participants. Quantitative analyses, using Tau-U, corroborated findings identified through visual analysis. The overall effect size was significant (Tau = .48, p  = .01). Results suggest that APT-3 has the potential to improve reading in individuals with aphasia, but that it may be more efficacious under certain conditions. Treatment and participant variables, including intensity of treatment and metacognitive strategy usage, are discussed as potential influences on participants' responsiveness to APT-3.

Studies suggest that individuals with aphasia present with impairments in attention. However, most research has been conducted with small sample sizes using experimental protocols that lack established psychometric properties. We examined the attention performance of 114 individuals with chronic post-stroke aphasia using a standardised, norm-referenced assessment of attention, the Conners' Continuous Performance Test-II (CPT-II; Conners, C. K. (2000). Conners' Continuous Performance Test II . Toronto: Multi-Health Systems Inc). Participants completed the CPT-II and the Western Aphasia Battery-Revised (WAB-R; Kertesz, A. (2007). Western Aphasia Battery-Revised . San Antonio, TX: PsychCorp). As a group, variable performance on selected CPT-II measures was observed. Participants demonstrated impairments on omissions (48.2%) and hit reaction time (67.5%), with 11.4% demonstrating atypically slow performance and over half of the sample (56.1%) performing atypically fast. The Confidence Index, a summary score, was also within the impaired range for the majority of participants. However, there were also measures in which a greater percentage of participants demonstrated performance within normal limits. Using the WAB-R Aphasia Quotient (AQ) as a measure of severity, there was significantly worse performance in participants with more severe (AQ < 50) compared to less severe (AQ ≥ 50) aphasia. No significant differences in attention were identified between participants with fluent versus non-fluent aphasia. The CPT-II is a feasible measure for persons with aphasia, which may assist in identifying attention performance deficits that potentially affect language.

Purpose This study reports on the treatment fidelity procedures implemented during a 5-year randomized controlled trial comparing intensive and distributed comprehensive aphasia therapy. Specifically, the results of 1 treatment, verb network strengthening treatment (VNeST), are examined. Method Eight participants were recruited for each of 7 consecutive cohorts for a total of 56 participants. Participants completed 60 hr of aphasia therapy, including 15 hr of VNeST. Two experienced speech-language pathologists delivered the treatment. To promote treatment fidelity, the study team developed a detailed manual of procedures and fidelity checklists, completed role plays to standardize treatment administration, and video-recorded all treatment sessions for review. To assess protocol adherence during treatment delivery, trained research assistants not involved in the treatment reviewed video recordings of a subset of randomly selected VNeST treatment sessions and completed the fidelity checklists. This process was completed for 32 participants representing 2 early cohorts and 2 later cohorts, which allowed for measurement of protocol adherence over time. Percent accuracy of protocol adherence was calculated across clinicians, cohorts, and study condition (intensive vs. distributed therapy). Results The fidelity procedures were sufficient to promote and verify a high level of adherence to the treatment protocol across clinicians, cohorts, and study condition. Conclusion Treatment fidelity strategies and monitoring are feasible when incorporated into the study design. Treatment fidelity monitoring should be completed at regular intervals during the course of a study to ensure that high levels of protocol adherence are maintained over time and across conditions.

Purpose: Intensity of therapy influences outcomes in aphasia treatment, but little is known about optimum dosage across treatment approaches. Improved understanding of the effects of dose could help facilitate clinical decisions that maximise patient outcomes. This study examines learning in individuals with aphasia following exposure to one 60-min dose of computer-delivered script training, with or without a rest break. Method: Twenty participants (6F, 14M; 17 nonfluent, 3 fluent) with chronic aphasia due to left-hemisphere stroke participated. Participants had a mean (SD) age of 56.9 (8.4) years, a mean time post onset of 55.1 (range: 6.4-396.4) months, and a mean (SD) Comprehensive Aphasia Test score of 47.8 (4.0). Participants were exposed to 60 min of training, with or without a rest break, of a three-turn conversational script about either weather or traffic. Treatment was delivered via computer using a virtual clinician that visually modelled speech and guided treatment, promoting treatment fidelity. Oral reading probes for script sentences were administered at baseline (3 times), mid-treatment, immediately post-treatment, and, at various times, up to 2 weeks post-treatment to track script acquisition and maintenance. The study also examined generalisation from a trained script to a conversation with a clinician via a generalisation probe at three time points: baseline, immediately post-treatment, and 2 weeks post-treatment. Result: Following exposure to one dose of script training, participants demonstrated statistically significant improvements in oral reading accuracy and rate of script production on trained probes from baseline to immediately post-treatment and 2 weeks post-treatment. Participants also demonstrated significant change from baseline in generalisation to a conversation with a clinician immediately post-treatment and at 2 weeks post-treatment. Conclusion: Exposure to a single dose of computer-delivered script training may facilitate learning. These results have implications for future research investigating optimal dosage and scheduling parameters.

Purpose Politeness markers (PMs) are words that enhance cooperativity in dialogue and are an essential component of professional/work communication. Persons with moderate/severe traumatic brain injury (TBI) underuse PMs in connected speech and have employment stability issues. The voicemail elicitation task (VET) is a standardized computerized language sampling procedure measuring PM rate in role-play tasks. Our purpose is to provide preliminary data establishing the potential of a screening assessment tool for professional/work communication. Method We measured VET performance using spoken PMs per minute (PMpM). We present data from 63 persons. Forty-three participants with TBI (22-65 years old, ≥ 1-year postinjury) worked in midlevel jobs before their injury and attempted work return after injury at the same job level. Twenty participants with TBI did not maintain work > 1 year (unstably employed), and 23 did maintain work for ≥ 1 year (stably employed). Twenty controls without history of neurological impairment working at the same job level also completed the VET protocol. We analyzed the data using between-group comparison with 1-way analysis of variance and post hoc analysis. We used receiver operating characteristic curve analysis to calculate sensitivity and specificity, as well as an optimal cutoff value for a screening measure. Results Group differences, F (2, 60) = 19.59, p = .0001, η 2 = .376, were identified between unstably employed persons with TBI performing with lower PMpM scores than the stably employed TBI group and the control group. Receiver operating characteristic curve analysis indicated a cutoff score of 11.55 PMpM. There was acceptable specificity (0.700, 95% CI [0.499, 0.901]) and sensitivity (0.696, 95% CI [0.508, 0.883]) for a screening tool indicating further assessment of social communication. Conclusion The VET holds promise as a clinical screening tool to identify persons at risk for social communication-related job instability after TBI and the need for a more comprehensive social communication assessment.

Purpose Dysphagia in Parkinson's disease (PD) is a major cause of depression and reduced quality of life (QOL). PD-related dysphagia often involves lingual dysfunction and weak pressure generation. The relation of disordered lingual pressure generation to swallowing-related QOL in persons with PD remains unknown. Method Twenty-four persons with idiopathic PD completed the Swallowing Quality of Life (SWAL-QOL) questionnaire and an evaluation of anterior and posterior tongue strength. Peak pressures were compared to age- and sex-matched controls. The magnitude of and latency to peak pressure were explored in relation to SWAL-QOL scores. Results Persons with PD exhibited significant anterior (p = .019) but not posterior (p = .081) lingual weakness compared to controls. Persons with PD and reduced anterior tongue strength (< 42 kPa) reported lower SWAL-QOL total (p = .043), extended eating durations (p = .025), and a reduced desire to eat (p = .020). Prolonged latency to peak anterior pressure in PD inversely correlated with SWAL-QOL total (r = -.750, p < .001) and served as a significant, independent predictor of 67% of the variance in SWAL-QOL total when controlling for age, sex, and disease stage. Conclusion Overall, SWAL-QOL scores declined in the presence of lingual pressure dysfunction. Lingual weakness and prolonged pressure building patterns secondary to PD, especially of the anterior tongue, may represent clinically relevant disruptions to mealtime behaviors that undermine swallowing-related QOL. These preliminary findings support further investigation of lingual pressure patterns in PD to help identify debilitating dysphagia and develop treatment strategies.

Objective: To investigate the prevalence of depression and subthreshold depression in persons with aphasia. To investigate whether there are linguistic and cognitive differences between those with depression, subthreshold depression, and no depression., Design: Survey., Setting: Rehabilitation hospital., Participants: Participants with chronic aphasia due to a single left-hemisphere stroke (N=144)., Main Outcome Measures: Center for Epidemiologic Studies Depression Scale to assess the prevalence of depression. The Western Aphasia Battery-Revised (WAB-R) to evaluate the type of aphasia; the Aphasia Quotient measured the severity of linguistic deficits., Results: The prevalence of depression in our participants was 19.44% while that of subthreshold depression was 22.22%. Depressed persons with aphasia had significantly lower WAB-R reading scores than those without depression., Conclusions: Findings suggest that persons with aphasia who have depressive symptoms may do worse on some linguistic measures than those with no depression. Since subthreshold depression can progress to depression, clinicians should routinely screen for depressive symptoms., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A core outcome set (COS; an agreed, minimum set of outcomes) was needed to address the heterogeneous measurement of outcomes in aphasia treatment research and to facilitate the production of transparent, meaningful, and efficient outcome data., Objective: The Research Outcome Measurement in Aphasia (ROMA) consensus statement provides evidence-based recommendations for the measurement of outcomes for adults with post-stroke aphasia within phases I-IV aphasia treatment studies., Methods: This statement was informed by a four-year program of research, which comprised investigation of stakeholder-important outcomes using consensus processes, a scoping review of aphasia outcome measurement instruments, and an international consensus meeting. This paper provides an overview of this process and presents the results and recommendations arising from the international consensus meeting., Results: Five essential outcome constructs were identified: Language, communication, patient-reported satisfaction with treatment and impact of treatment, emotional wellbeing, and quality of life. Consensus was reached for the following measurement instruments: Language: The Western Aphasia Battery Revised (WAB-R) (74% consensus); emotional wellbeing: General Health Questionnaire (GHQ)-12 (83% consensus); quality of life: Stroke and Aphasia Quality of Life Scale (SAQOL-39) (96% consensus). Consensus was unable to be reached for measures of communication (where multiple measures exist) or patient-reported satisfaction with treatment or impact of treatment (where no measures exist)., Discussion: Harmonization of the ROMA COS with other core outcome initiatives in stroke rehabilitation is discussed. Ongoing research and consensus processes are outlined., Conclusion: The WAB-R, GHQ-12, and SAQOL-39 are recommended to be routinely included within phases I-IV aphasia treatment studies. This consensus statement has been endorsed by the Collaboration of Aphasia Trialists, the British Aphasiology Society, the German Society for Aphasia Research and Therapy, and the Royal College of Speech Language Therapists.