Attention training for aphasia: here and now!

The treatment of aphasia has a rich and beautiful history with documented treatments as early as the 1960s. For the most part, the treatment of aphasia at the impairment level has been guided by representational treatment approaches or processing approaches. Both have substantial evidence for their efficacy, but of course, we are always looking for ways to better improve the communication of our clients with aphasia.

Recently, there has been some attention *future pun intended* in the literature about resource theory and aphasia treatment. From this angle, language impairment in aphasia stems from difficulty using cognitive resources like attention and memory.  

Since around 2000, researchers have been studying whether or not directly treating attention and related cognitive processes improve language outcomes for people with aphasia. Results of multiple studies have been mixed, but overall it seemed that treating attention for aphasia could be promising.  

Most studies for attention training and aphasia outcomes thus far have largely been relegated to a “domain general” approach—this means that a variety of cognitive processes are targeted. These approaches have used nonlinguistic, paper and pencil and/or computer-based tasks to directly train attention in a more general way.  

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In this study, a specific approach to attention training in aphasia rehab was studied—Language-Specific Attention Training (LSAT). L-SAT is a specific attention training program because it is designed to focus attention to increasingly difficult language tasks.

Researchers in the study compared L-SAT to direct attention training (DAT), as delivered by computer-based tasks, in four participants with aphasia. L-SAT was superior to DAT across the treatment tasks themselves, a standardized language test and a measure of functional communication. Patient reported outcome measures were better with L-SAT as well. As you well know, research with this heterogenous population is complex, and it’s important to check out the original article for more context for the results.

The ENTIRE manual of the L-SAT is FREE! The program is laid out step by step with specific procedures, discontinuing rules, and again FREE. The article also states that audio-visual stimuli for the program are available from the first author, Dr. Peach.

Although more research on L-SAT is needed, there’s a clear, evidence-based, FREE, guide as to how to implement this treatment with your clients with aphasia, so pay attention, specifically!

 

Peach, R.K., Beck, K.M., Gorman, M., & Fisher, C. (2019). Clinical outcomes following language-specific attention treatment versus direct attention training for aphasia: A comparative effectiveness study. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2019_JSLHR-L-18-0504.

Is a subjective measure of intelligibility as good as an objective measure of intelligibility?

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It is 4:45 PM. You’re frantically trying to finish up a report so you can be out the door by 5:00. The evidence-based practitioner in you is determined to provide an objective measure of intelligibility in your comprehensive speech and voice evaluation for your client with Parkinson’s Disease (PD). So, you obtain a 3-minute audio recording of the ‘Caterpillar Passage.’ You listen and compare your client’s performance to the transcribed version, carefully marking words understood. Ten minutes later, you’re only 50% of the way through the recording because you had to stop multiple times to transcribe what you actually heard. And, you still need to count the total number of words understood so you can calculate the percent intelligibility score… And, it’s 5:15.  

Isn’t there a quicker way of measuring intelligibility? 

The good news is, yes, there is! Abur et al. found that the use of a visual analog scale (VAS) was a feasible way to measure intelligibility. The relationship between orthographic transcription (OT) and VAS was strong regardless of whether raters were rating a short or long speech sample, or if the speech samples were produced by speakers with or without PD.

This relationship, though, was dependent upon having at least two listeners/raters use the VAS. Let’s break this down: If only the treating SLP uses VAS, the average difference between OT and VAS is 8%— MORE than the 7% average treatment effect of Lee Silverman Voice Treatment (LSVT LOUD). If the SLP grabs a colleague to also rate, the difference between VAS and OT drops to a much more acceptable range, 4.5%. Figure 4 captures this effect very nicely.  

A notable fact was that all the listeners were naïve—they were neither trained to assess speech intelligibility, nor did they have exposure to speech-impaired individuals prior to this study. This allows flexibility for SLPs to choose even non-SLP colleagues to be the 2nd rater.  

This study builds on an emerging body of work that also found objective and subjective measures of intelligibility to be highly correlated with listeners who are unfamiliar with evaluating disordered speech. Along with being an accurate predictor of intelligibility, VAS is also feasible given the time constraints of clinical settings. The authors found that listeners took an average of 5 minutes to rate 28 sentences using VAS as opposed to 9 minutes for the OT condition – short enough to convince a colleague to do you a solid and provide a rating!

So, how do we use VAS? Here’s one way:

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Or, use software!  

Office scene, now: It’s 4:45 PM and you’re about to rate a client’s speech intelligibility after listening to an audio recorded sample of him reading. You pull out your VAS, grab the physical therapist (PT) (who owes you a favor anyway), and done by 4:55. Out the door you go! Remember to grab an extra coffee for that PT who helped you in the morning!  

Abur, D., Enos, N.M, & Stepp, C.E. (2019). Visual Analog Scale Ratings and Orthographic Transcription Measures of Sentence Intelligibility in Parkinson’s Disease With Variable Listener Exposure. American Journal of Speech–Language Pathology. doi:10.1044/2019_AJSLP-18-0275.

Reducing risk of mild cognitive impairment with mentally stimulating activities—when, what, how many and how much?

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In 2017, Krell-Roesch et al. found that cognitively unimpaired older adults (aged ≥ 70 years) who engaged in mentally stimulating activities reduced their risk of mild cognitive impairment (MCI). And, this month these researchers are back with more details!

Now they wanted to know whether engaging in mentally stimulating activities in midlife AND late life reduced risk of MCI when compared to adults who only engaged in these activities in midlife OR late life. So, timing of engagement was the first question. Then, they looked at how many of these mentally stimulating activities the participants needed to do. Do individuals need to engage in a variety of these activities to reduce their risk? Or, is one or two activities enough? Finally, how often should we recommend our clients complete these types of activities to see the benefit?

These are some big questions from a big study. Two thousand participants were tracked for a median time of five years, using self-reported data. The five mentally stimulating activities analyzed were:

  1. Reading books

  2. Computer use

  3. Social activities (hanging out with friends, going to the movies)

  4. Playing games (crossword puzzles, playing cards)

  5. Craft activities (pottery, quilting, or sewing) 

Before we get to the good stuff, what is the everyday application of this study? You could make the case that typically, SLPs do not see clients with MCI until they have a diagnosis.  However, ASHA defines our scope to include prevention of communication disorders. And this study does give us some concrete, modifiable lifestyle factors that we can encourage our aging clients to consider.

So, how about some specific results?  

First, the what and when questions:

Participants who engaged in computer use demonstrated decreased risk of MCI no matter when they started to participate—whether that be in midlife (50–65) or after the age of 70. Unfortunately, the study doesn’t provide details as to what this computer use entails.

Participants who engaged in craft activities in midlife did not reduce their risk of MCI, BUT those who engaged in craft activities AFTER the age of 70 years did decrease their risk.

Participants who engaged in social activities and games ONLY reduced their risk of MCI if they participated in midlife AND late-life.

Now, the how much and how often questions:

Overall, we don’t really know. There was no consistent “dose-response pattern” between the number of times per week or month the participant had to engage in the activity to see the reduced risk of MCI. It seems 2–3 times per month is enough for most activities; however, computer use needed to be completed at least 5–6 per week to decrease the risk of MCI. What we also don’t know from this study is how long each person should participate in each activity. For example, do you need to play cards for 15 minutes or 2 hours to get the benefits?

Broadly though, even late life engagement in mentally stimulating activities can reduce MCI risk for those who are cognitively unimpaired.  

Researchers caution that individuals who complete a variety of mentally stimulating activities may also engage in greater physical activity or eat a healthier diet. These habits have also been shown to be protective factors when it comes to MCI risk. Further, engaging in “leisure activities” may lend itself to better emotional health and this has been associated with improved cognitive function as well. We owe our older adults evidence-based solutions for the prevention of MCI—results of this study seem like a good place to start!

 

Krell-Roesch, J., Syrjanen, J.A., Vassilaki, M., Machulda, M.M., Mielke, M.M., Knopman, D.S., Kremers, W.K., Petersen, R.C., & Geda, Y.E. (2019). Quantity and quality of mental activities and the risk of incident mild cognitive impairment. Neurology. doi: 10.1212/WNL.0000000000007897.

Throwback (2019): What can we learn from healthy swallows across liquid consistencies?

Can you tell the difference between normal and abnormal swallow features in a videofluoroscopic swallow study (VFSS)? Can your colleagues? Vose et al. (2018) found that 77% of surveyed SLPs identified at least 5 normal aspects of a swallow to be disordered. EEEEK!

It’s clear as a field that we need to be better able to distinguish disordered swallows from normal ones.  So, what can we do? Well, let’s start by looking at some new data from Steele et al. (2019) on healthy swallows across the liquid International Dysphagia Diet Standardization Initiative (IDDSI)* levels.  While most of the swallows were textbook normal—one swallow per sip, Penetration-Aspiration Scale (PAS) of 1, full laryngeal closure, no residue—there was more variation in young, healthy swallows than you might think. Here are some findings that you can use when interpreting your next VFSS:

  • Bolus location at swallow onset does not tell us anything about how “normal” a swallow is. For thin, slightly thick, and mildly thick boluses, the head of the bolus could be anywhere in the pharynx at swallow onset. In fact, the most common location (36% of the time) for a thin liquid bolus at the time of hyoid burst was in the pyriform sinuses. Note that all of the swallows in this study were non-cued.

  • There were also more second swallows than you might expect. While most natural sips were completed in one swallow, in 20% of trials the participants swallowed a second time. Again, normal variation. Also, these second swallows did not happen more frequently with thicker liquids.

  • Most young, healthy people scored a PAS of 1 on all their swallows. Not surprising. But a number of people in this sample scored a PAS of 2 on at least one trial, with one participant scoring PAS of 5 on two swallows. This might not be news to readers of The Informed SLP, but it is a good reminder to not overinterpret infrequent penetration. On the other hand, if you read this review and are surprised that there wasn’t more penetration and aspiration among young, healthy participants in this study, remember that most people who penetrated or aspirated in Butler et al. (2018) were over 60 and that Butler used endoscopy (FEES) not VFSS.

This paper is chock full of data on the sequence, timing, and movements during various swallowing events at each IDDSI level. Want to know the average swallow reaction time for mildly thick liquids? Hop over to Table 2 and go wild. Want to know if maximum hyoid excursion changes for different consistencies? Check out Table 6 (spoiler alert: the answer is no.) This paper offers a ton of data showing how increasing thickness of liquids affects swallow physiology.

One caveat of this study is that it was completed with 20% w/v barium mixtures that were thickened by xanthan gum. This is different from the 40% w/v barium in Varibar that is most commonly used in the United States. At the moment, we still don’t have the research to know whether barium brand or small differences in concentration matter. For more on this issue see this article or this article by the Steele Swallowing Lab.

Note: You may be wondering if this article has data you can use today to determine whether a feature like swallow onset timing is within normal limits or delayed. The answer is yes, but not without doing some calculations on your own. Dr. Steele addresses this question more in the comments section, below. The good news is that Dr. Steele and her team are putting together multiple resources, including a case-based ASHA presentation this November, to make these reference data as accessible and useful to clinicians as possible. We’ll update this review once those resources are available.

Also: To hear Dr. Steele discuss this study herself, click here.

* If you’re not yet familiar with the IDDSI framework, check it out here. For now, here’s a cheat sheet:

  • Thin

  • Slightly thick ≈ Between thin and nectar thick

  • Mildly thick ≈ Nectar thick

  • Moderately thick ≈ Honey thick

  • Extremely thick ≈ Puree

 

Steele, C. M., Peladeau-Pigeon, M., Barbon, C. A. E., Guida, B. T., Namasivayam-MacDonald, A. M., Nascimento, W. V., … Wolkin, T.S.  (2019) Reference Values for Healthy Swallowing Across the Range From Thin to Extremely Thick Liquids. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2019_JSLHR-S-18-0448. 

Throwback (2019): Video-animation helps patients with head and neck cancer better understand their swallow prognosis

After hearing the words, “You have head and neck cancer,” it is not hard to believe that patients do not immediately think of the implications that treatment will likely have on their swallowing. SLPs serve an important role in pretreatment counseling to prepare these patients for the potential development of dysphagia during and post-treatment. Indeed, patients are often dealing with exhaustion, pain, poor appetite, financial stress, and the overwhelmingness of their diagnosis Govender et al. conducted a qualitative study to see if video-animation as an education tool (compared to a written handout or pamphlet) would be useful & acceptable for patients to understand swallowing and dysphagia.

Patients were first shown a still image for anatomical orientation. They were then shown a “normal swallow” animation and then a “disordered” swallow animation representative of post-radiation (one with pharyngeal residue, effortful swallowing, and multiple swallowing attempts). During the first video, a clinician explained the normal swallow events. Then, the participant was asked to narrate what they saw during the second video, using what researchers refer to as a “think aloud” method. 

Researchers utilized the following strategies:

  • Paused video as needed

  • Allowed opportunity to replay the video

  • Slowed down the speed of the video

  • Provided simple cueing like, “Tell me what you’re thinking,” to encourage participation

Participants indicated that the animations were useful, interesting, and relevant. Several participants reported that if they had viewed the animations with explanation earlier, they would have been more likely to complete prophylactic swallowing exercises. The researchers propose that using video-animation as a visual support seemed to make the typically “unconscious” swallowing process more “concrete” than traditional diagrams or handouts. 

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One limitation to this study is that participants were not newly diagnosed. All had some experience with swallowing treatment and the rehabilitation process. However, these preliminary results suggest that newly diagnosed patients may also benefit from education with video animations.

 

Govender, R., Taylor, S.A., Smith, C.H., & Gardner, B. (2019).  Helping Patients With Head and Neck Cancer Understand Dysphagia:  Exploring the Use of Video-Animation.  American Journal of Speech-Language Pathology.  doi:10.1044/2018_AJSLP-18-0184.