Neurostimulation for drug-resistant epilepsy : a systematic review of clinical evidence for efficacy, safety, contraindications and predictors for response

Purpose of review: Neurostimulation is becoming an increasingly accepted treatment alternative for patients with drug-resistant epilepsy (DRE) who are unsuitable surgery candidates. Standardized guidelines on when or how to use the various neurostimulation modalities are lacking. We conducted a systematic review on the currently available neurostimulation modalities primarily with regard to effectiveness and safety. Recent findings: For vagus nerve stimulation (VNS), there is moderate-quality evidence for its effectiveness in adults with drug-resistant partial epilepsies. Moderate-to-low-quality evidence supports the efficacy and safety of deep brain stimulation (DBS) and responsive neurostimulation (RNS) in patients with DRE. There is moderate-to-very low-quality evidence that transcranial direct current stimulation (tDCS) is effective or well tolerated. For transcutaneous vagus nerve stimulation (tVNS), transcranial magnetic stimulation (TMS) and trigeminal nerve stimulation (TNS), there are insufficient data to support the efficacy of any of these modalities for DRE. These treatment modalities, nevertheless, appear well tolerated, with no severe adverse events reported. Summary: Head-to-head comparison of treatment modalities such as VNS, DBS and RNS across different epileptic syndromes are required to decide which treatment modality is the most effective for a given patient scenario. Such studies are challenging and it is unlikely that data will be available in the near future. Additional data collection on potentially promising noninvasive neurostimulation modalities like tVNS, TMS, TNS and tDCS is warranted to get a more precise estimate of their therapeutic benefit and long-term safety

The protective influence of bilingualism on the recovery of phonological input processing in aphasia after stroke

Language-related potentials are increasingly used to objectify (mal)adaptive neuroplasticity in stroke-related aphasia recovery. Using preattentive [mismatch negativity (MMN)] and attentive (P300) phonologically related paradigms, neuroplasticity in sensory memory and cognitive functioning underlying phonological processing can be investigated. In aphasic patients, MMN amplitudes are generally reduced for speech sounds with a topographic source distribution in the right hemisphere. For P300 amplitudes and latencies, both normal and abnormal results have been reported. The current study investigates the preattentive and attentive phonological discrimination ability in 17 aphasic patients (6 monolinguals and 11 bilinguals, aged 41-71 years) at two timepoints during aphasia recovery. Between the two timepoints, a significant improvement of behavioral language performance in both languages is observed in all patients with the MMN latency at timepoint 1 as a predictive factor for aphasia recovery. In contrast to monolinguals, bilingual aphasic patients have a higher probability to improve their processing speed during rehabilitation, resulting in a shortening of the MMN latency over time, which sometimes progresses toward the normative values

The feasibility, usability and acceptability of a tablet-based aphasia therapy in the acute phase following stroke

Question: Independent practice via an application with a language exercise program for aphasia, as an add-on to conventional care can be a good solution to intensify aphasia therapy. The aim of this prospective trial was to investigate the feasibility, usability and acceptability of the newly developed aphasia exercise program in the 'Speech Therapy App (STAPP)' in the acute phase post-stroke. Methods: All eligible people with aphasia following stroke (<2 weeks post-stroke) admitted to the Stroke Unit of Ghent University Hospital were recruited in this prospective clinical trial between September 2018 and December 2019. After linguistic assessments and two short training sessions, participants were asked to practice independently with 'STAPP' for at least 30 min/day during hospitalization. Exercises were individually tailored and adjusted if necessary. Outcome was measured by recruitment, adherence and retention rates, usability questionnaires and a visual analogue scale for satisfaction. Results: Twenty-five (mean age 65 years (SD = 17), 14 females) of 31 eligible people with aphasia were enrolled in this trial (recruitment rate = 81 %). All participants but one (23/24) practiced with the language app until the end of hospitalization (retention rate = 96 %). Ten participants practiced at least 30 min/day (adherence rate = 42 %). Participants reported they learned to work quickly with the app (92 %; agreed/totally agreed), the app was easy to use (88 %), they could work independently (79 %), practiced their language (67 %) and wanted to continue working with the app at home (79 %). Acceptability was high (median satisfaction rate 91 %; IQR = 75-100). Conclusion: The aphasia exercise program in 'STAPP' is feasible to use as an additional rehabilitation tool along with standard of care in the acute phase post-stroke. Further research is needed to assess the efficacy. Clinical Trial Registration-URL: https://clinicaltrials.gov/ct2/show/NCT03679637

Dysphagia, dysarthria and aphasia following a first acute ischemic stroke : incidence and associated factors

Background and purpose Dysphagia, dysarthria and aphasia are common symptoms following acute stroke; however, limited data are available from recent prospective clinical trials. The aim of this study was to determine the incidence and associated factors of dysphagia, dysarthria and aphasia following a first acute ischaemic stroke in patients admitted to a comprehensive stroke center. Methods All first ischaemic stroke patients admitted to the Stroke Unit of Ghent University Hospital within 48 h after symptom onset were enrolled in this prospective study between March 2018 and October 2019. Dysphagia and communication screenings were performed within 3 days after admission. When dysphagia, dysarthria and/or aphasia were assumed, standardized assessments were performed. Incidence rates were calculated as point estimates (%) with 95% confidence intervals (CI). Associated factors were calculated via multivariate binary logistic regression analyses. Results Dysphagia, dysarthria and aphasia were present in 23% (95% CI, 17-31), 44% (95% CI, 37-52) and 23% (95% CI, 17-30), respectively of 151 first ischaemic stroke patients [67 female, mean age 67 (SD 14) years]. Separate multivariate binary logistic regression analyses showed that dysphagia, dysarthria and aphasia were significantly associated with age-adjusted stroke severity at baseline [odds ratio (OR), 1.16; 95% CI, 1.09-1.23; OR, 1.13; 95% CI, 1.07-1.20 and OR, 1.11; 95% CI, 1.05-1.17 respectively]. Corrected for stroke severity, the risk for aphasia increased by 4% per year of age (OR, 1.04; 95% CI, 1.00-1.07). Adjusted for age and stroke severity, aphasia was significantly associated with large artery atherosclerosis as stroke etiology (OR, 3.91; 95% CI, 1.18-12.98). Conclusions This trial showed a high incidence of dysphagia, dysarthria and aphasia following acute ischaemic stroke. Stroke severity was an associated factor for all three symptoms

Effectiveness of chewing technique on the phonation of female speech-language pathology students : a pilot study

Objectives. The purpose of this study was to determine how use of the vocal facilitating technique, chewing, affected the phonation of speech-language pathology (SLP) students. Study Design. A pretest-posttest randomized control group design was used. Methods. Twenty-seven healthy female SLP students were randomly assigned into either an experimental group or a control group. The experimental group practiced chewing exercises across 18 weeks, whereas the control group received no vocal facilitating techniques. Both groups completed pre- and post- objective voice assessment measures (aerodynamic measurement, acoustic analysis, voice range profile, and Dysphonia Severity Index). Differences between pre- and post-data were compared between the experimental and control group using an independent sample t test. Results. Compared to the control group, chewing resulted in a significant decrease in jitter and noise-to-harmonic ratio (NHR), a significant increase in fundamental frequency (f(o)), a significant expansion of the voice range profile, and a significant increase in Dysphonia Severity Index (DSI). Shimmer and maximum phonation time (MPT) were not significantly different between groups. Conclusions. The results of this pilot study suggest that the vocal facilitating technique, chewing, may improve objective vocal measures in healthy female SLP students