Aphasia After Therapy

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Recently, Breitenstein et al. Interestingly, none of their participants dropped out of the study, which mitigates the concern raised by the latest Cochrane review 1. Despite growing evidence regarding the importance of intensity and dose in aphasia therapy, patients with aphasia receive far less than what is considered intensive therapy in clinical settings 3. Several studies have compared intensive and less intensive aphasia treatment behaviorally [e. Since intensity may be an important factor in maximizing neuroplasticity in recovery from brain damage, a study contrasting the effects of intensive and non-intensive treatment is required.

Preliminary to such an undertaking in substantial patient cohorts, we used functional magnetic resonance imaging fMRI to investigate the neural changes associated with anomia treatment in two patients: Importantly, both patients received the same amount of therapy overall and both received the same treatment for anomia, the phonological components analysis PCA treatment approach.

Phonological components analysis is a sound-based therapy in which participants are asked to identify five phonological components e. We and others have shown that PCA treatment improves naming performance in patients who suffer from chronic non-fluent or fluent aphasia 7 — 9 following a left hemisphere stroke.

Improved naming after standard PCA treatment has been associated with neural activation changes in left hemisphere areas e.

How speech and language therapy can help

Thus, the aim of this case report is to use this well-established specific treatment to better understand the brain plasticity mechanisms associated with the intensity of delivery of aphasia treatment. She worked as a teacher and in administration. He had hypertension, coronary artery disease, and dyslipidemia.

The patient worked in television production prior to the stroke. Both patients were monolingual English speakers, wear reading glasses, and passed a hearing screening test. There was no history of memory loss or any other neurological disorder at the time of stroke. The neurological examination of both patients also revealed right hemiparesis and right hypoesthesia.

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Both patients participated in a larger group study investigating the behavioral differences in treatment outcomes associated with intensive versus standard PCA treatment Both patients provided free and informed consent to participate in the experiments, which were conducted with the approval of the Research Ethics Board at Baycrest Centre, Toronto, ON, Canada. Written informed consent was obtained from both participants for the publication of these case reports.

A Axial MRI images showing the lesions resulting from a left ischemic stroke in the middle cerebral artery territory. B Reconstruction in 3D of the brain lesion of both patients.

Upper and lower images are from the patient who received the intensive condition and the patient who received the standard regimen, respectively. Patients were randomly assigned to treatment condition. Afterward, patients received PCA treatment 7. This occurred after 2. During both fMRI sessions, patients performed an overt naming task. We used a series of tests to assess the different aspects of language abilities before PCA treatment began.

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The assessment included the following tests: Stimuli for the naming task were color pictures presented on a white background. To provide individualized treatment, stimuli for PCA treatment were selected on the basis of individual performance on the baseline evaluation. Therefore, each patient was treated with different stimuli. Two sets of words were created for each patient: Words were pseudo randomly assigned to either the treated or the untreated condition.

The PCA treatment was conducted in multiple sessions according to the procedures described in Leonard et al.

Optimal timing of speech and language therapy for aphasia after stroke: more evidence needed.

Briefly, the examiner presents a target picture in the center of a chart and asks the patient to name the picture. Once completed, the patient tries to name the target once again. Then the examiner reviews all five phonological components and the patient tries to name the target a third time. Treatment under the short-term intensive condition was provided for patient P1 over a period of 2.

Ten-minute breaks were incorporated every hour. The fMRI sessions used an event-related design. The experimental stimuli from which 48 were treated, including 18 words that were repeated were presented in three separate runs. Participants were instructed to name each picture, as clearly and accurately as possible, while avoiding head movements. Visual stimuli were delivered using standard software Presentation software v. Patients viewed the projection screen through an angled mirror attached to the head coil.

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Anatomical and functional MR images were acquired using a 3. Patients lay supine on the MRI patient table with their head stabilized by foam padding. Analyses were performed to separate blood-oxygen-level dependent BOLD responses for each trial type. For each participant, task-related BOLD changes were examined by convolving a vector of naming onset with the hemodynamic response function and its temporal derivative.

Preprocessed data were analyzed using the general linear model implemented in SPM Statistical parametric maps were obtained for each individual participant, by applying linear contrasts to the parameter estimates for the events of interest; this resulted in a t -statistic for every voxel. Individual maps were calculated for each condition of interest by employing a one-sample t -test without constant term random effects on the resulting contrast image. Optimal anatomical localization was based on the Montreal Neurological Institute MNI template brain of SPM12 as well as on Talairach coordinates 17 which were obtained using a non-linear transformation 3 18 and labeled using the Talairach Daemon applet 4 19 , Improvement following treatment was observed for treated words, but not for untreated words see Figure S1 in Supplementary Material.

Top row Brain activation changes for participant P1 who received the intensive phonological components analysis PCA. Similar to results obtained in our previous studies 7 , 10 , language production by two patients with chronic non-fluent aphasia was improved by PCA, although the change was only significant for the patient in the intensive condition.

The improvements were also found to be long lasting as both patients showed maintained treatment effects at 1- and 2-month follow-ups. The associated fMRI data indicate that improved naming performance for treated words was mainly associated with decreases in activation following therapy for the patient who received intensive treatment, whereas the patient who received the standard PCA treatment showed increased cortical activity bilaterally. Decrease of activation has been associated with more efficient processing following therapy in patients suffering from aphasia 21 — Consistent with this evidence, the present results suggest that the active engagement of the participant who received the intensive PCA treatment was associated with more decreases than increases in activation, which we attribute to more efficient processing.

It should be noted that only P1 who received the intensive treatment showed a significant improvement in naming during treatment, and this improvement was obtained in a very short period of time 2. These results confirm previous findings that treatment related changes in activation can be observed within a very short period of time 24 — By contrast, increased neural activity in distributed bilateral areas was observed for participant P2 who received the standard regimen.

Greater increases of activation may be due to less efficient or malfunctioning processing We note that increase of activation was also found in participant P1. It was somewhat unexpected initially to find that the activation changes for the patient who received intensive PCA were observed in the right caudate nucleus. However, a growing body of evidence suggests that the caudate nucleus is involved in cognitive control, including language control processing 27 , 28 and in particular in the selection of the most relevant language features and the inhibition of irrelevant ones.

In a recent study, Gronholm et al. This finding supports the growing body of evidence which indicates that the caudate nucleus is involved in procedural learning in language tasks 30 , which may be associated with automaticity. Similarly, a significant increase in activation was observed for participant P2 in the right anterior cingulate, which is also involved in the suppression of irrelevant words in language production We speculate that the recruitment of the caudate nucleus and the anterior cingulate reflects the need to suppress errors to improve naming ability.

The present work has some limitations. The results from these cases serve as a starting point for investigating the effects of treatment intensity. These findings need to be replicated with larger sample sizes 32 , while also bearing in mind that one potential limitation of group analyses in stroke patients is the variability that characterizes both the language impairments and the location of the stroke Accordingly, previous group studies using fMRI have reported substantial variability for individual patients with aphasia [e.

Another potential caveat of these case studies is the sex difference between the two participants. Regarding treatment outcome, the improvement was not statistically significant for P2. It is possible that changes in activation for this patient reflected random inter-session variance. However, P2 maintained his posttreatment performance, including the difference between his treated and untreated words, at both follow-up sessions, which argues against this possibility. In addition, the present analyses were based on both correctly and incorrectly named words, as the number of words correctly named was not sufficient for distinct separate analysis.

Finally, the functional changes observed in the present study may be related to the effect of practice on the task during scanning 41 , rather than the therapy. However, overt naming tasks using overtrained pictures are generally considered to involve a decrease of activation and can still be suitable for longitudinal studies in poststroke aphasia as long as overtrained pictures are randomly mixed with novel e.

In conclusion, both short-term intensive and standard, non-intensive, PCA treatment improved word retrieval of two chronic aphasia patients.

The associated neuroimaging data suggest that improved naming is associated with different neural activation patterns in the two treatment conditions. CL and ER supervised the study. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The Supplementary Material for this article can be found online at https: Accuracy of production of treated and untreated words as a function of treatment condition.

National Center for Biotechnology Information , U. Journal List Front Neurol v. Published online Apr 9. Meltzer , 3, 6, 7, 8 Simon J. Graham , 9, 10 Carol Leonard , 3, 8, 11 and Elizabeth Rochon 3, 4, 8, Author information Article notes Copyright and License information Disclaimer.

New method could transform aphasia treatment after stroke

This article was submitted to Stroke, a section of the journal Frontiers in Neurology. Received Jan 8; Accepted Mar The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Abstract Despite the growing evidence regarding the importance of intensity and dose in aphasia therapy, few well-controlled studies contrasting the effects of intensive and non-intensive treatment have been conducted to date. Introduction According to the most recent Cochrane review 1 , high-intensity aphasia therapy leads to reduced aphasia severity and greater functional improvement in communication than low-intensity therapies, but may lead to a higher dropout rate.

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