711 NeuroRehabilitation 35 (2014) 711–717 DOI:10.3233/NRE-141175 IOS Press Case Study Should individuals with chronic aphasia be treated with dedicated PC-based training? Considerations about a case study Rosaria De Luca, Rocco Salvatore Calabrò∗ , Simone Reitano, Giuseppina Digangi, Francesco Bertè, Giuseppa Sergi and Placido Bramanti IRCCS Centro Neurolesi, “Bonino Pulejo”, Messina, Italy Abstract. OBJECTIVE: Aim of this study was to evaluate the effects of an emerging rehabilitative tool (“Power-AFA” - software) in the recovery of a patient with chronic non-fluent aphasia. MATERIAL AND METHODS: A 56-year-old woman, affected by post-stroke severe expressive aphasia, underwent two different intensive rehabilitation trainings, including either standard language rehabilitation alone or a proper PC based speech training in addition to conventional treatment. We evaluated her cognitive and psychological profile in two separate sessions, before and after the two different trainings, by using a proper psychometric battery, to assess cognitive status, language abilities, and to estimate the presence of mood alterations and coping strategies. The overall PC-program was articulated in 6 sessions/weekly for 3 months. RESULTS: Only at the end of the PC-training, we observed an important improvement in peculiar cognitive domains (attention and memory functions), in denomination, in verbal understanding ability, in written, in communication skills as well as an optimization of the mood and coping styles. CONCLUSIONS: Computer-based cognitive and language rehabilitation, using proper and dedicated software, may be a valuable tool in improving either communication or cognitive skills in patient affected by aphasia, even in the chronic state. Keywords: PC-training, chronic aphasia, stroke 1. Introduction Stroke is a common, serious, and disabling global health-care problem and rehabilitation represents the main component of patient care (Warlow 2008). Approximately one-third of people suffering from stroke may experience a communication disorder. ∗ Address for correspondence: Rocco Salvatore Calabrò, MD, PhD, IRCCS Centro Neurolesi, “Bonino-Pulejo”, S.S. 113, Contrada Casazza, 98124 Messina, Italy. Tel.: +39 090 60128954; Fax: +39 090 60128950; E-mail: salbro77@tiscali.it. Indeed, one of the most frequent symptoms of unilateral stroke is aphasia, i.e. the impairment or loss of language function. Aphasia is the most frequent cognitive disorder (risk of aphasia is 20–40%) in the stroke population (Salter 2005). It is defined as a reduction of the patient’s ability to communicate by language expression (in Broca’s aphasia) and comprehension (in Wernicke’s aphasia) and can affect all aspects of communication performance. Brain damage in peculiar cerebral areas causes aphasia of different types and severities, depending on the location and the extent of the lesion. Thus, 1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved 712 R. De Luca et al. / Aphasia PC-based rehabilitation some or all language modalities, including expression and understanding of speech, reading and writing, may be affected. Moreover, non-linguistic cognitive impairment may be associated to aphasia, limiting rehabilitation efficacy (Murray 2012). Today, there is good evidence that aphasia treatment is effective if sufficiently prolonged and that chronic aphasic subjects can also benefit from rehabilitation regimen, but data on chronic aphasia are scantly (Cherney 2010; Katz 2010; Basso, 1998, 2011). Aten et al. (1982) showed that in seven chronic aphasic patients the communicative abilities in daily living (CADL) test scores revealed statistically significant improvement in post-treatment performances. Interestingly, the effect of treatment for aphasia are synthesized and assessed for the following dimensions: amount of treatment, type of treatment, severity of aphasia, and type of aphasia (Robey 1998). Four meta-analyses (Robey 1994, 1998; Rohling 2009; Whurr 1992); and two evidence based reviews (Cappa 2003; Cicerone 2005) concluded that treated aphasic subjects improved their language abilities more than untreated subjects. Although numerous marketed software have been developed for the language rehabilitation of individuals with aphasia, the effectiveness of this approach remains still limited, especially in chronic aphasia. Nevertheless, growing evidence (Brady 2012) is demonstrating the usefulness of Speech and Language Therapy in the rehabilitation of aphasia, with regard to the improvement of functional communication, and receptive and expressive performances. Current works concerning the application of computerbased rehabilitation in the treatment of aphasia are demonstrating promising results. In particular, it has been showed that success in aphasia therapy is linked to a high treatment frequency. Thus numerous computer applications have been developed for rehabilitation of language disorders (Van de Sandt-Koenderman 2011). The therapeutic benefits of specific programs have been reported for anomia (Ramsberger 2007), conversational scripts (Cherney 2008), sentence processing and comprehension, communication skills (Raymer 2006) and sentence construction and spelling (Crerar 1996). Computers and related technology can increase the amount of treatment also in adults with chronic aphasia. In this sense, Archibald et al. (2009) evaluated a comprehensive computer-based language therapy program (Aphasia MateTM software, www.avaaz.com ) in eights individuals with chronic aphasia. As a result, the patients showed an overall therapeutic benefit in auditory comprehension and a positive trend in functional communication (Archibald 2009). In this case report, we tried to evaluate the effects of a dedicated software, i.e. Power AFA, which is specifically aimed at the treatment of language and cognitive communication disorders, in a patient with chronic nonfluent aphasia. 2. Methods 2.1. Case description A 56-year-old right-handed housewife, affected by post-stroke expressive aphasia and right hemiparesis, came to our observation for intensive rehabilitation. Her psychomotor development was normal. She reported graduating from secondary school. At the time of testing, she was married with two kids and did not have any experience in using computers. She had been affected by hypertension and ischemic heart disease for 20 years, and she had been treated with sartans (valsartan 80 mg/daily) and clopidrogel (75 mg/daily). In February 2012, she was admitted to a Neurosurgical ward for left nucleo-capsular hemorrhage, treated with decompressive craniectomy and subsequent cranioplasty without neurological complications (after about two months). The patient then came to our Research Institute to perform intensive conventional language rehabilitation; (consisting of the stimulation of phonetic abilities, semantic process and writing skills to recourse to standard rehabilitate tool) from April to July 2012. However, at the end of this first traditional rehabilitative cycle, the language and cognitive recovery wasn’t so relevant (except a mild improvement in selective attention) at the end of this first traditional rehabilitative cycle (see Fig. 1a). For this reason, at her readmission to our Centre (November 2012), we decided to stimulate the residual cognitive and language resources through intensive computerized language training with a specific rehabilitative tool (software namely Power-AFA) in addition to conventional neurorehabilitation. 2.2. Experimental tasks and procedures Neuropsychological status was assessed by an experienced neuropsychologist through a proper battery to investigate cognitive domains such as attention, memory, learning and executive functions. The battery included Mini Mental State Examination (MMSE) R. De Luca et al. / Aphasia PC-based rehabilitation 713 Fig. 1. a) Language evaluation before (T0) and after only conventional rehabilitation (T1). b) Language evaluation before (T0) and after PC training in addition to standard treatment (T1). (Folstein 1975), the Attentive Matrices (AM) (Spinnler 1987), Trial Making Test A and B (TMT A; TMT B) (Giovagnoli 1996), Digit Span test (DS) (Orsini 1987) and Reversal Motor Learning (RML) (Spinnler 1987). Moreover we used: i) the Aachen Aphasie Test (AAT) (Huber 1983) to assess spontaneous speech, comprehension and communication skills; ii) the Hamilton Rating Scale for Depression (HRS-D) (Hedlund 1979) to evaluate the presence of the depressive symptoms; and iii) The Coping orientation to problems experienced- New Italian Version (COPE-NIV) (Sica 2008) to measure coping styles in five essentially independent broad dimensions, including social support (ss), voidance strategies (vs), positive attitude (pa), problem solving (ps) and turning to religion (tr). The entire battery was administered either before or after treatments. The intensive computerized-language training, i.e. the Power-AFA software was performed in addition to the conventional speech therapies. Thus, the rehabilitation program included three different stages: stage A, i.e. pre-treatment (baseline data and evaluation without aid); stage B, i.e. treatment, and stage A, i.e. post - treatment (re-evaluation without aid), in the proper ABA design (see Fig. 2). The rehabilitative treatment with “Power -AFA” was articulated in 6 sessions/weekly for 3 months (for a total of 72 rehabilitative sessions). Power AFA is an emerging Italian pc-based rehabilitative tool used to improve language disorders and other cognitive dysfunction in aphasic patients. The dedicated software consists of a great variety of exercises, i.e. sound exercises, image recognition exercises, word and letter exercises, verbs and actions recognition exercises. This rehabilitative tool suits to different types of patients, with different levels of language difficulty or of personal background complexity. A virtual therapist helps and stimulates patients during their training. The program enables the therapist to use different types of pc-tasks: i) The phonological task stimulates the auditory skills for the comprehension of names and actions. The process was repeated to increase the patient’s performance. ii) The semantic task consists of deciphering materials belonging to several semantic fields. Such task included also questions of personal evaluation of the material. 714 R. De Luca et al. / Aphasia PC-based rehabilitation Fig. 2. ABA design for aphasia treatment. iii) The written task implied copying, listening and transcription of audio tasks. iv) The mixed task combines morphological and syntactic exercises on selected categories (animals, colors, body parts, fruits, food, frequently asked questions, action verbs and furniture). The training implies periodical increase of difficulty levels (easy, moderate and difficult pc-task), in relation to the achieved objectives. 3. Results At T0 session, patient’s AAT showed severe deficits including phonemic paraphasias and “conduites d’approche”, and alterations in oral and written comprehension of language. Indeed, her Token test results were 23/0 - NS:52; whereas her understanding was 83/120-NS:49. Furthermore, morph-syntactic alterations (agrammatism) made communication very difficult. A reading and writing combined disabling deficit was also found (written language 40/90-NS:48). The patient was not able to denominate things, people and actions (denomination 63/120-NS:46), or fluently repeat words and phrases (repetition 125/150-NS:55). Consequently, the presence of mild depressive symptom (HRS-D: 10) was diagnosed too. The case of study also showed a moderate global cognitive alteration (MMSE:21) with inadequate and dysfunctional coping strategies. Moreover, she showed invaliding selective and sustained attention deficits (AT = 24.25). Attention shifting, psychomotor speed, the capacity of response to inhibition (TMT A = 81; B = 196) short term memory (DS = 3.75) and learning process were also compromised (RML = 10). The patient’s emotional distress produced avoidance strategies, whereas her positive attitude and problem solving were related to reduced distress and greater psychological well-being. Lastly, social support and turning to religion were not associated with psychological well-being. Comparison between pre and post-treatment AAT scores showed an improvement in different language abilities (see Fig. 1b). In particular, at time T1, we observed an improvement in denomination 76/120-NS:50; language R. De Luca et al. / Aphasia PC-based rehabilitation 715 Table 1 Psychometric evaluation before (T0) and after Power-AFA training (T1), combined to standard treatment Domains Test + (Range) T0 T1 21/30 5 5 3 0 3 2 0 3 24.25/ ≥ 49 23/30 5 5 3 2 3 2 0 3 32.25 / ≥ 49 Short term memory Learning process MMSE (0–30) Subtest MMSE (0–5) Subtest MMSE (0–5) Subtest MMSE (0–3) Subtest MMSE (0–5) Subtest MMSE (0–3) Subtest MMSE (0–2) Subtest MMSE (0–3) Subtest MMSE(0–3) AM (≤30 / ≥ 49) TMT A – B TMT-A (≥94 / ≤ 44) TMT-B (≥283/ ≤ 102) DS (0–9) RML (≤18,25/ > 23) 81 / ≤ 44 196/ ≤ 102 3.75/ 9 10/ > 23 83/ ≤ 44 195/ ≤ 102 5.5 /9 10/ > 23 Depression Symptoms Coping Style Range Social Support Range Voidance strategies Range Positive Attitude Range Problem Solving Range Turning to religion HRS–D (0–≥25) COPE - NVI (74 / 218) Sub-test Cope (12/48) Sub-test Cope (16/64) Sub-test Cope (12/48) Sub-test Cope (12/48) Sub-test Cope (22/10) 10 / ≥ 25 117 22 21 29 22 23 4 / ≥ 25 127 26 18 33 27 23 General Cognitive Status Orientation to time Orientation to place Registration Attention and calculation Recall Language Repetition Complex commands Selective and sustained attention Attention process/attention shifting NS = Normalized score. AAT = Aachen Aphasie Test. MMSE = Mini Mental State Examination. COPE-NIV = Coping orientation to problems experienced - New Italian Version. DS = Digit Span. AM = Attention Matrices. HRS-D (Hamilton rating scale for depression). TMT = Trial Making Test. comprehension 106/120-NS:61; token test 17/0-NS:55. Thus a clear reduction of errors in auditory-language processing tasks was shown. The patient’s written language resulted in 55/90 - NS:52, her communication skills and mood results were (HRS-D:4). However, the repetition was stable 127/150-NS:55. Moreover, a positive improvement trend in global cognitive functioning (MMSE = 23), in selective attention (Attentive matrices = 32.25), in short term memory (Digit Span Test = 5.5) and in coping styles was also observed (see Table 1). 4. Discussion In spite of the limitations of our study to one individual case and the lack of comparison with other non-specific intensive computer-base training, we were able to find out an improvement in the patient’s language functions, communication’s ability and mood after a proper pc-training. Therefore, we realized the additional use of an intensive Power-AFA training may be a promising tool in cognitive recovery, with regard to language abilities even in chronic patients. Nowadays, the increasing use of Information Technology demands pc-based cognitive and linguistic rehabilitation, although clinical data are still scant and need to be confirmed. Computer-based training may increase the amount of treatment in individuals with severe neuropsychological deficits, including aphasia. In this sense, Aftonomos et al. (1997) showed that specific areas of language function can be positively and significantly influenced by computer-based language therapy in chronic aphasia and that the recovery in these patients can be promoted by interactive technology (Katz 1997). Katz and Wertz (1997) promoted the efficacy of computer-provided reading activities on language performance (visual matching, reading comprehension tasks, non verbal games and cognitive rehabilitation tasks) in chronic aphasic patients (Katz 1997). Furthermore, Laganaro et al. (2006) analyzed the outcome of computer-assisted therapy (CAT) for anomia on eight acute aphasic patients (Laganaro 2006), suggesting that the effect of the therapy depends on the number of treated items rather than the number of repetitions per item. Additional data have been reported by Fridrikson et al. (2009) who showed the positive effects of computerized visual speech training on naming and general communication abilities (Fridriksson 2009). According to the aforementioned literature, our study showed that computer-based programs can be a valid additional 716 R. De Luca et al. / Aphasia PC-based rehabilitation treatment in the rehabilitation of speech disorders (with regard to verbal anomies and written abilities) and general communication skills. Pc-training also offers positive influence on coping strategies, mood and cognitive functioning. We believe our patient’s evident improvement in cognition, mood and language function may be partly related to such intensive pc-rehabilitation program. Indeed, the patient did not present any significant improvement during her first attendance to our Institute, when she performed only a traditional speech therapy. Thus, the active combination of the latter with computerized and more motivating tools may have been more effective in improving neuropsychological functions. In recent years, there has been a growing interest in the application of new software for cognitive rehabilitation, especially in patients with chronic neurological disorders. Indeed, Marcotte et al. (2012) have observed that the therapy may induce changes also in the chronic phase, since brain plasticity is possible even after 6 months from the acute event. Neuroplasticity is activated from the intensive rehabilitation treatment, and it can be enhanced by neurophysiological techniques, such as transcranial magnetic (TMS) and electrical stimulation, as demonstrated by Barwood et al. (2013) in chronic non-fluent aphasia. Indeed, the hypothesis that TMS may modulate the brain mechanisms is supported by evident transcallosal inhibition in the aphasic brain. Therefore the potential clinical application of TMS for language rehabilitation in chronic aphasia proves to be consistent. 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