Furthermore it appears that the mechanisms of change associated with facilitators may be used in more varied combinations during therapy. However, the most effective combination of mechanisms to support change in conversation barriers and facilitators is unknown at this stage.
Clearly, changing conversation behaviors through conversation therapy is a complex process that will need further investigation to ensure it is optimally effective. It is also possible that the process of measuring change in facilitators and barriers by using frequency counts influenced the contrast in findings for facilitators and barriers. Whereas barriers by their nature are expected to decrease or disappear, facilitators may become more frequent, but they may instead be used more effectively while not increasing significantly in numbers.
For example, a PWA may use writing as a strategy both before and after intervention; the effectiveness of this strategy within conversation may alter as a result of therapy, but not be reflected in counts of writing behavior. In addition, given that facilitators represent a range of behaviors already in use in conversation, it is unclear how much of an increase needs to happen for therapy to be considered successful. To counter this difficulty, we have attempted in other publications, see for example Beeke et al.
In this study video was used with both PWA and CPs to raise awareness, promote reflection on the consequences of their conversational behaviors, and to permit them to reflect immediately on the successes and failures of strategy use in practice conversations. This promoted in-depth self-reflection and, by the very nature of video feedback, rendered the task concrete and accessible to PWA, not just their CPs.
Arguably it would not have been possible to discuss abstract concepts such as turns and repair without using video-playback techniques, since speakers are generally unaware of the conversational rules that govern their interactions. In addition, speakers with aphasia are likely to experience significant difficulties with expressing views on conversation behaviors in the absence of concrete examples to scaffold such discussions.
As Simmons-Mackie et al. Video feedback would seem to be a crucial element to ensure the likely success of this form of strategy training for PWA.
Indeed, as the case series findings show, two PWA significantly increased their use of facilitators in conversation post therapy.
Given that generalization of learnt strategies to everyday interaction in aphasia rehabilitation is an ever-present challenge, understanding the role of video feedback in conversation therapy is a priority for systematic investigation in future research.
The inclusion of IRR is relatively new in the field and brings a level of confidence to the results. However, as the IRR results for our conversation outcome measure reveal, reliably rating conversation behaviors is not straightforward. One factor that influenced IRR was the natural variability of behaviors across conversation samples and dyads, a feature of conversation first systematically noted in relation to attempts at quantification by Perkins et al.
Thus some behaviors were present for all dyads whereas some were specific to one dyad only, and some behaviors occurred throughout the conversation samples whereas others occurred only sporadically. Also, there is the issue of interpretation of IRR levels for conversation data.
However, the Oelschlaeger and Thorne study ultimately found that reliable CIU measures could not be obtained for everyday conversation. This is not surprising given the analytic focus on transaction of information to the detriment of interactional features that permit the establishment and maintenance of interpersonal relationships.
As the largest group study in the field which deploys a measure of targeted behaviors, it presents group and case series analyses of pre- and post-therapy samples of everyday conversation, the expected site of communication behavior change following this type of intervention. While 32 dyads completed the protocol for the Wielaert et al.
As Wilkinson and Wielaert and Simmons-Mackie et al. Group results often hide the improvement that can be made after intervention; in this study a case series design reveals how individual dyads can make significant gains after conversation therapy.
A strength of the study is the collection and analysis of multiple pre and post-therapy conversations; this enabled patterns to emerge over and above the noise inherent in behavioral data from everyday interaction.
An analysis of TF found the delivery of therapy was in line with the intervention protocol, suggesting that BCA can be delivered as intended.
Furthermore, the program appears to be acceptable to PWA and CPs of different ages, educational backgrounds, dyadic relationships and severity of aphasia.
Of the nine dyads referred to the study, only one did not complete it; they reported that they would prefer an impairment based intervention, specifically targeting speech output. Results underline the need for SLPs to tailor conversation skills training, and to consider the fact that video feedback may be crucial for generalization, although it is accepted that further evidence is needed before this can be concluded to be a vital part of such interventions. The results also show that intervention can assist communication in the absence of clear and clinically meaningful improvement on standard language tests.
This is important, as a key aim of work on language in clinical practice and in some research is to improve everyday communication. The finding that everyday conversations change after video intervention work that targets conversation directly, provides clear confirmation that this is another approach that can be added to those already in use by SLPs. Finally, the study reveals the possibility of improving the everyday communication skills of some PWA many months beyond the period of spontaneous recovery.
Seven of the eight dyads showed significant change at case series level and these included PWA at 59 and 60 months post stroke. We now turn to the limitations of the study and implications for future research. From the perspective of the hierarchy of evidence, the fact that the study did not have a control group is a major concern. However, it is not clear what would be a suitable control, particularly given the heterogeneous nature of both aphasia and conversation.
Furthermore, matching on conversation variables would be crucial for such a design and as shown in the data in Tables 2 , 3 , no two dyads show similar profiles at the level of total conversation barriers and facilitators. This is also the case for individual behaviors such as use of test questions, and gesture. Given this variability, a design in which participants act as their own control is the most likely to inform understanding.
Future research might employ a cross-over design comparing work on conversation with a very different intervention e. While this limitation holds for research, in practice, when therapy is flexible, it may well be appropriate to work directly on a language skill e. While the study is one of the largest in the field, inclusion of more dyads would strengthen the research and would enable further exploration of candidacy issues Turner and Whitworth, ; Eriksson et al.
Future studies, with more participants, could also explore in more depth the finding that it may be easier to reduce barrier behaviors than increase facilitator behaviors.
This is particularly important given the clinical implications. A tentative suggestion would be that in selecting goals for conversation intervention, SLPs should facilitate PWA and CPs to select at least one barrier behavior each, rather than a set limited to facilitator behaviors.
While the inclusion of additional dyads in research would enable exploration of such issues, there is a tension present. Due to inevitable resource limitations, including more participants is likely to entail a corresponding reduction in the depth and richness of data collected and analyzed for each dyad. Future research could also explore issues of dosage bearing in mind adequate time is likely to be necessary between sessions for homework and consolidation and intensity.
Use of BCA principles and particularly use of video feedback in conversation should be explored in other populations including those with fluent aphasias, and primary progressive aphasia see Volkmer, as a starting point. The related approach of Parent Child Interaction PCI has been shown to be effective at changing the conversations between pre-school children with language needs and their parents Falkus et al.
In conclusion, this article adds to the evidence base for use of conversation approaches with PWA and their CPs. The dramatic decrease in barrier behaviors after eight sessions of intervention suggests change can be expected within a clinically realistic timescale.
The experimentally controlled case series with careful correction of multiple comparisons demonstrates that findings for the group for example the lack of a significant increase in facilitators are not necessarily the same as those for individual dyads. This highlights the importance of reporting findings beyond the group level. Further exploration of use of video technology in conversation therapy should be a research priority. WB led on the quantification of aspects of conversation, the writing of this article and carried out the analysis of conversation facilitators and barriers for the group and case series.
JM led the collection and compilation of connected speech data and the IRR analysis. CH led on fidelity and under the supervision of SB and WB assembled all the data from the student projects and compiled Appendices 2 and 3. FB recruited all participants to the study, assessed them and carried out the intervention.
SIE led on inclusion criteria and facilitated recruitment to the study. DH supplied the Poisson Trend Test and provided advice on statistical analysis. 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.
Lizz Summers, an SLP on a research placement with the team, contributed to the literature search and designed one of the figures. Jyrki Tuomainen for advice on statistical analysis of the formal assessment data. Bastiaanse, R. Brain Lang. The Verb and Sentence Test. Bury St. Google Scholar.
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In the process of melody in guiding the target language, the pitch of the melody comes from the natural pronunciation of Mandarin Chinese. The patient began to sing and slowly generalized into speaking. These fixed-pitch formulaic melody languages range from 2 to 5 short sentences to 7—10 long sentences Supplementary Materials , that is, to create lyrics of daily life language with a fixed melody, teach patients to sing, and then slowly get out of the melody, and the pitch becomes speaking.
This is an entirely different approach from speech therapy intervention. The formation of pitch melody completely simulates the laws of Chinese phonetics. In the second part, after MIT, if the patient can imitate the pitch but cannot imitate the Chinese character sound, they will use MUSTIM to sing familiar songs to guide the words that cannot be expressed verbally.
The choice of the song is not blind. When the music therapist chooses the song, the lyrics will include the vocabulary of the target language. After the familiar cognitive melody is guided, the patient is guided back to the model singing of the formulaic melody, so that the patient can imitate and say it. This is why aphasia patients in the MIT group performed particularly prominently in the repetition items. When the patient sings each short melody or song, it is accompanied by a guitar or piano and other harmonic instruments.
Due to the interaction of the left and right hemisphere networks when the brain processes language information, when the auditory center receives multiple stimulations, they jointly activate the output of emotion, memory, and spoken language. Therefore, in this study, the MIT group in the BDAE score has improved listening comprehension, repetition, spontaneous speech, and naming. One limitation was the limited sample, as previously detailed.
Two participants dropped out of the study, which may have caused the variance in group allocation. If a blank, the control group was added to observe self-healing, and the comparison might have been more accurate.
This study only recruited 40 patients. If larger-sized studies are conducted in the future, the therapeutic outcomes could be more precisely observed. Besides, the participants with three different types of non-fluent aphasia are included into the trial. Although they belong to non-fluent aphasia, they also belong to different subtypes. If more samples can be included in future studies and different subtypes of aphasia are classified and compared, the effect comparison of the two methods will be clearer.
In previous reports in the literature, clinicians usually recommend speech therapy to train the patients with aphasia but neglected that the function of song singing played an important role in speech output. Although MIT has been proposed and used in the s, it is often used by speech therapists.
Given that professionals with a musical background, that is, music therapists, will have a more professional understanding of music or songs, and the operability of the musical instrument, the MIT performed by the music therapist will provide multiple auditory stimulation to the patients to activate more potential brain networks and better restore language ability.
Through this study, we confirmed the positive effect of the MIT performed by a music therapist in 20 aphasia patients. All the participants in the intervention group were more active in every aspect of AQ than the control group, which provided a more effective way for speech recovery of aphasic patients.
Music therapists with professional backgrounds provide multiple auditory stimuli with instrumental accompaniment and fixed-pitch melody formulaic language during the treatment process, which are all necessary conditions for the implementation of MIT. The MIT performed by music therapists has a more obvious effect on improving the language function of patients with non-fluency aphasia.
Therefore, it is recommended that clinicians and professional music therapists work together to make the clinical treatment effect more remarkable. W-YY supported the assessment. W-ZW was the principal investigator of this project. J-JL was the corresponding author. All authors contributed to the article and approved the submitted version.
It is a national non-profit foundation program and was approved by the Ministry of Finance of China. The funding sources had no role in the study conception and design, data analysis or interpretation, manuscript writing, or deciding to submit this manuscript for publication. 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. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.
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Sihvonen, A. Music-based interventions in neurological rehabilitation. Sparks, R. Spreen, O. Assessment of Aphasia. Most often, the cause of the brain injury is a stroke. A stroke occurs when a blood clot or a leaking or burst vessel cuts off blood flow to part of the brain. Brain cells die when they do not receive their normal supply of blood, which carries oxygen and important nutrients.
Other causes of brain injury are severe blows to the head, brain tumors, gunshot wounds, brain infections, and progressive neurological disorders, such as Alzheimer's disease.
There are two broad categories of aphasia: fluent and nonfluent, and there are several types within these groups. Damage to the temporal lobe of the brain may result in Wernicke's aphasia see figure , the most common type of fluent aphasia.
People with Wernicke's aphasia may speak in long, complete sentences that have no meaning, adding unnecessary words and even creating made-up words. For example, someone with Wernicke's aphasia may say, "You know that smoodle pinkered and that I want to get him round and take care of him like you want before.
As a result, it is often difficult to follow what the person is trying to say. People with Wernicke's aphasia are often unaware of their spoken mistakes. Another hallmark of this type of aphasia is difficulty understanding speech.
The most common type of nonfluent aphasia is Broca's aphasia see figure. People with Broca's aphasia have damage that primarily affects the frontal lobe of the brain. They often have right-sided weakness or paralysis of the arm and leg because the frontal lobe is also important for motor movements. People with Broca's aphasia may understand speech and know what they want to say, but they frequently speak in short phrases that are produced with great effort.
They often omit small words, such as "is," "and" and "the. For example, a person with Broca's aphasia may say, "Walk dog," meaning, "I will take the dog for a walk," or "book book two table," for "There are two books on the table. Because of this, they are often aware of their difficulties and can become easily frustrated. Another type of aphasia, global aphasia, results from damage to extensive portions of the language areas of the brain.
Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again.
They may have trouble understanding even simple words and sentences. There are other types of aphasia, each of which results from damage to different language areas in the brain. Some people may have difficulty repeating words and sentences even though they understand them and can speak fluently conduction aphasia. Others may have difficulty naming objects even though they know what the object is and what it may be used for anomic aphasia. Sometimes, blood flow to the brain is temporarily interrupted and quickly restored.
When this type of injury occurs, which is called a transient ischemic attack, language abilities may return in a few hours or days. Aphasia is usually first recognized by the physician who treats the person for his or her brain injury.
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