Dopaminergic therapy in aphasia

Background: The dopaminergic system is involved in a wide range of cognitive functions including motor control, reward, memory, attention, problem-solving and learning. This has stimulated interest in investigating the potential of dopaminergic drugs as cognitive enhancers in aphasic patients. / Aim: To discuss the evidence for the use of dopaminergic agents in patients with aphasia. Levodopa (L-dopa) and the dopamine agonist bromocriptine are the two drugs that have been trialled to date. We discuss, in some detail, the 15 studies that have been published on this topic from the first case report in 1988 to the present (2012), and assess the evidence from each. / Main contribution: In addition to summarising the effectiveness of the drugs that have been tried, we examine the possible cognitive mechanisms by which dopaminergic drugs may act on language function and aphasia recovery. Given the wide range of dopaminergic drugs, it is surprising that such a narrow range has been trialled in aphasic patients. Important lessons are to be learned from published studies and we discuss optimal trial designs to help guide future work. / Conclusions: The evidence for the efficacy of dopaminergic agents in aphasia therapy is mixed. Further trials with better tolerated agents are required. Optimal trial designs with appropriate control groups or blocks should be used. The mechanism of action is unclear, but at the cognitive level the evidence points towards either (re)learning of word-forms or their improved retrieval

Using functional imaging to understand therapeutic effects in poststroke aphasia

PURPOSE OF REVIEW: The evidence base for the treatment of poststroke aphasia continues to grow, so too does interest in the neural mechanisms that underlie these therapy-driven improvements. Although the majority of patients respond to therapy, not all of those who do improve do so in a predictable way. Here, we review 17 of the most recent articles that have attempted to deal with this important question, dividing them into those that target speech perception and production. RECENT FINDINGS: There are many methodological differences between the studies, but some neuroimaging patterns have emerged: whether the in-scanner language task is speech perception or production, left hemisphere fronto-temporal cortex is often activated/correlated with language improvement and; right inferior frontal gyrus is frequently identified although what this represents is still hotly contested. We are concerned that many studies are not well controlled making it difficult to ascribe neuroimaging changes directly to the therapeutic intervention. SUMMARY: Encouragingly, there are many more functional imaging studies in this challenging area of research. Behaviour, either alone or paired with structural imaging data, only goes part way in explaining aphasic patients’ responses to therapy. An important emerging theme is exploring the role that nonlanguage cognitive processes play in aphasia recovery

Web-based therapy for hemianopic alexia is syndrome-specific

Rehabilitation studies rarely test the specificity of an intervention by using a control group who are matched to the therapy group in terms of baseline impairment, but who do not have the same causative syndrome. In this study, we tested the specificity of an eye movement therapy for a common, acquired reading disorder called hemianopic alexia, by comparing hemianopic participants with slow text reading, to age and reading speed matched controls without hemianopia. The study was carried out using an online therapy programme called ‘Read-Right’ that contains validated tests of the visual field and text reading speed, as well as an eye movement therapy: laterally scrolling text. 201 self-selected participants completed at least 5 h of online therapy. After excluding those with reading speeds incompatible with hemianopic alexia and those with bilateral abnormalities on their visual field test, we were left with 105 who were then classified into one of three groups depending on their visual field: (1) right-sided hemianopia (n=47); (2) left-sided hemianopia (n=36); (3) no hemianopia (n=22, control group). The three groups did not differ in terms of baseline text reading speed, but they were all significantly slower than expected based on normative data from the same age range. A repeated-measures analysis of variance showed a significant therapy by group interaction (p=0.039). Post hoc, paired t tests revealed that this was driven by reading speed improvements for the right-sided and left-sided hemianopic alexic groups but not the controls. This result demonstrates that a clinically validated therapy for hemianopic alexia improves text reading speed in hemianopic patients but not in participants matched for slow text reading but without hemianopia. This adds weight to the hypothesis that eye movement therapies are syndrome-specific. It also demonstrates an advantage of using web-based vehicles to deliver syndrome-specific therapies that can be accessed by patients worldwide

Facilitating text reading in posterior cortical atrophy

Objective We report 1) the first quantitative investigation of text reading in posterior cortical atrophy (PCA); and 2) the effects of two novel software-based reading aids that result in dramatic improvements in PCA patients' reading ability. Methods Reading performance, eye movements and fixations were assessed in PCA and typical Alzheimer’s disease (tAD) patients and healthy controls (Experiment 1). Two reading aids (single- and double-word) were evaluated based on the notion that reducing the spatial and oculomotor demands of text reading might support reading in PCA (Experiment 2). Results PCA patients’ mean reading accuracy was significantly worse (57%) compared to both tAD patients (98%) and healthy controls (99%); spatial aspects of passages were the primary determinants of text reading ability in PCA. Both aids led to considerable gains in reading accuracy (PCA mean reading accuracy: single-word reading aid = 96%; individual patient improvement range: 6%-270%) and self-rated measures of reading. Data suggest a greater efficiency of PCA patients’ fixations and eye movements under the single-word reading aid. Conclusions These findings demonstrate how neurological characterisation of a neurodegenerative syndrome (PCA) and detailed cognitive analysis of an important everyday skill (reading) can combine to yield aids capable of supporting important everyday functional abilities. Classification of evidence This study provides Class III evidence that for patients with posterior cortical atrophy, two software-based reading aids (single-word and double-word) improve reading accuracy

Can fully automated detection of corticospinal tract damage be used in stroke patients?

We compared manual infarct definition, which is time-consuming and open to bias, with an automated abnormal tissue detection method in measuring corticospinal tract-infarct overlap volumes in chronic stroke patients to help predict motor outcome

Between Thought and Expression, a Magnetoencephalography Study of the "Tip-of-the-Tongue" Phenomenon

“Tip-of-the-tongue” (TOT) is the phenomenon associated with the inaccessibility of a known word from memory. It is universally experienced, increases in frequency with age, and is most common for proper nouns. It is a good model for the symptom of anomia experienced much more frequently by some aphasic patients following brain injury. Here, we induced the TOT state in older participants while they underwent brain scanning with magnetoencephalography to investigate the changes in oscillatory brain activity associated with failed retrieval of known words. Using confrontation naming of pictures of celebrities, we successfully induced the TOT state in 29% of trials and contrasted it with two other states: “Know” where the participants both correctly recognized the celebrity's face and retrieved their name and “Don't Know” when the participants did not recognize the celebrity. We wished to test Levelt's influential model of speech output by carrying out two analyses, one epoching the data to the point in time when the picture was displayed and the other looking back in time from when the participants first articulated their responses. Our main findings supported the components of Levelt's model, but not their serial activation over time as both semantic and motor areas were identified in both analyses. We also found enduring decreases in the alpha frequency band in the left ventral temporal region during the TOT state, suggesting ongoing semantic search. Finally, we identified reduced beta power in classical peri-sylvian language areas for the TOT condition, suggesting that brain regions that encode linguistic memories are also involved in their attempted retrieval

Generative Embedding for Model-Based Classification of fMRI Data

Decoding models, such as those underlying multivariate classification algorithms, have been increasingly used to infer cognitive or clinical brain states from measures of brain activity obtained by functional magnetic resonance imaging (fMRI). The practicality of current classifiers, however, is restricted by two major challenges. First, due to the high data dimensionality and low sample size, algorithms struggle to separate informative from uninformative features, resulting in poor generalization performance. Second, popular discriminative methods such as support vector machines (SVMs) rarely afford mechanistic interpretability. In this paper, we address these issues by proposing a novel generative-embedding approach that incorporates neurobiologically interpretable generative models into discriminative classifiers. Our approach extends previous work on trial-by-trial classification for electrophysiological recordings to subject-by-subject classification for fMRI and offers two key advantages over conventional methods: it may provide more accurate predictions by exploiting discriminative information encoded in 'hidden' physiological quantities such as synaptic connection strengths; and it affords mechanistic interpretability of clinical classifications. Here, we introduce generative embedding for fMRI using a combination of dynamic causal models (DCMs) and SVMs. We propose a general procedure of DCM-based generative embedding for subject-wise classification, provide a concrete implementation, and suggest good-practice guidelines for unbiased application of generative embedding in the context of fMRI. We illustrate the utility of our approach by a clinical example in which we classify moderately aphasic patients and healthy controls using a DCM of thalamo-temporal regions during speech processing. Generative embedding achieves a near-perfect balanced classification accuracy of 98% and significantly outperforms conventional activation-based and correlation-based methods. This example demonstrates how disease states can be detected with very high accuracy and, at the same time, be interpreted mechanistically in terms of abnormalities in connectivity. We envisage that future applications of generative embedding may provide crucial advances in dissecting spectrum disorders into physiologically more well-defined subgroups

Auditory training changes temporal lobe connectivity in 'Wernicke's aphasia': a randomised trial

INTRODUCTION: Aphasia is one of the most disabling sequelae after stroke, occurring in 25%-40% of stroke survivors. However, there remains a lack of good evidence for the efficacy or mechanisms of speech comprehension rehabilitation. TRIAL DESIGN: This within-subjects trial tested two concurrent interventions in 20 patients with chronic aphasia with speech comprehension impairment following left hemisphere stroke: (1) phonological training using 'Earobics' software and (2) a pharmacological intervention using donepezil, an acetylcholinesterase inhibitor. Donepezil was tested in a double-blind, placebo-controlled, cross-over design using block randomisation with bias minimisation. METHODS: The primary outcome measure was speech comprehension score on the comprehensive aphasia test. Magnetoencephalography (MEG) with an established index of auditory perception, the mismatch negativity response, tested whether the therapies altered effective connectivity at the lower (primary) or higher (secondary) level of the auditory network. RESULTS: Phonological training improved speech comprehension abilities and was particularly effective for patients with severe deficits. No major adverse effects of donepezil were observed, but it had an unpredicted negative effect on speech comprehension. The MEG analysis demonstrated that phonological training increased synaptic gain in the left superior temporal gyrus (STG). Patients with more severe speech comprehension impairments also showed strengthening of bidirectional connections between the left and right STG. CONCLUSIONS: Phonological training resulted in a small but significant improvement in speech comprehension, whereas donepezil had a negative effect. The connectivity results indicated that training reshaped higher order phonological representations in the left STG and (in more severe patients) induced stronger interhemispheric transfer of information between higher levels of auditory cortex.Clinical trial registrationThis trial was registered with EudraCT (2005-004215-30, https://eudract.ema.europa.eu/) and ISRCTN (68939136, http://www.isrctn.com/)

Cross-language differences in the brain network subserving intelligible speech

SIGNIFICANCE: Language processing is generally left hemisphere dominant. However, whether the interactions among the typical left hemispheric language regions differ across different languages is largely unknown. An ideal method to address this question is modeling cortical interactions across language groups, but this is usually constrained by the model space with the prior hypothesis due to massive computation demands. With cloud-computing, we used functional MRI dynamic causal modeling analysis to compare more than 4,000 models of cortical dynamics among critical language regions in the temporal and frontal cortex, established the bias-free information flow maps that were shared or specific for processing intelligible speech in Chinese and English, and revealed the neural dynamics between the left and right hemispheres in Chinese speech comprehension. ABSTRACT: How is language processed in the brain by native speakers of different languages? Is there one brain system for all languages or are different languages subserved by different brain systems? The first view emphasizes commonality, whereas the second emphasizes specificity. We investigated the cortical dynamics involved in processing two very diverse languages: a tonal language (Chinese) and a nontonal language (English). We used functional MRI and dynamic causal modeling analysis to compute and compare brain network models exhaustively with all possible connections among nodes of language regions in temporal and frontal cortex and found that the information flow from the posterior to anterior portions of the temporal cortex was commonly shared by Chinese and English speakers during speech comprehension, whereas the inferior frontal gyrus received neural signals from the left posterior portion of the temporal cortex in English speakers and from the bilateral anterior portion of the temporal cortex in Chinese speakers. Our results revealed that, although speech processing is largely carried out in the common left hemisphere classical language areas (Broca’s and Wernicke’s areas) and anterior temporal cortex, speech comprehension across different language groups depends on how these brain regions interact with each other. Moreover, the right anterior temporal cortex, which is crucial for tone processing, is equally important as its left homolog, the left anterior temporal cortex, in modulating the cortical dynamics in tone language comprehension. The current study pinpoints the importance of the bilateral anterior temporal cortex in language comprehension that is downplayed or even ignored by popular contemporary models of speech comprehension