Episode #63: The Interesting Mix of Discourse, Neural Plasticity, Fidelity and Song: A Conversation with Jessica Richardson

Janet Patterson, Ph.D., CCC-SLP, Chief of the Audiology & Speech-Language Pathology Service at VA Northern California, speaks with Jessica Richardson, Ph.D., CCC-SLP, about aphasia, neural recovery, treatment outcome measures, and discourse, all at the center of her study to improve communication and life participation in persons with aphasia. These Show Notes are an abridged version of the conversation with Jessica. Jessica Richardson, Ph.D., CCC-SLP is an associate professor and speech-language pathologist in the Department of Speech and Hearing Sciences at The University of New Mexico. She is director of the Neuroscience of Rehabilitation Laboratory, the SPACE (Stable and Progressive Aphasia CEnter) within, and the UNM Neurochoir. She is also Outreach Director for the Center for Brain Recovery and Repair at The University of New Mexico Health Sciences Center. Her research focus is on improving assessment and treatment for adults with communication disorders following acquired brain injury (e.g., post-stroke aphasia, post-TBI cognitive-communication disorder) or due to progressive disease (e.g., primary progressive aphasia) in order to improve participation in everyday life activities. Her lab also studies the impact of brain stimulation on brain structure and function, as well as on behavioral outcomes, in these populations. She uses structural and functional neuroimaging (e.g., EEG, MRI) alongside narrative assessment (and other behavioral measures) to identify diagnostic biomarkers and/or to characterize recovery, disease trajectory, and response to treatment. Dr. Richardson is a 2020 Tavistock Distinguished Aphasia Scholar, USA. In the comments and highlights Below you will read about Jessica’s work and the influence the Tavistock award has had on her career. Janet: How has being named a Tavistock Distinguished Scholar USA for 2020 influenced your continued work in aphasia clinical research? Jessica: This award has reenergized my work. As we go along in our careers it can become easy to lose track of our mission and, as I did, begin to ask why I am following this path. The Tavistock award has a focus on helping people change the lives of people with aphasia, and  receiving this award reminded me of my mission and why I am here doing what I do every day, especially in 2020 which we all recognize posed an extra challenge to life. In addition, the Tavistock award supports networking with people around the country and the world to talk about ideas and building a bright future. Janet: Much of your work in aphasia has focused on measuring discourse production in persons with aphasia, in particular, conveying main concept information. How do you see production of main concepts in a discourse event as important in supporting successful communication between persons with aphasia and their communication partners?   Jessica: As you know, there are hundreds of discourse analysis measures out there. I began examining discourse using Brookshire & Nicholas’ CIUs – a measure that has power and limits and that clinicians both love and do not love. Brookshire & Nicholas also wrote about using Main Concepts as a measure of discourse and after reading about it, I was hooked! However, I could not find any tools using Main Concepts and so decided to do something about that. Communication requires that we give and receive information and the idea of Main Concepts focusses on packaging the gist of the information so partners will understand each other. If the packaging is faulty then the communication can be poor or can fail. Measuring and targeting how people package the gist of what they want to say is useful for our patients. Main Concept Analysis in assessment of person with aphasia is a psychometrically sound procedure, and clinically useful, but it only takes us so far because information has to also be organized. My team and I are expanding Main Concept Analysis by looking at story grammar and sequencing, using Main Concept Sequencing and Story Grammar Analysis because we know the packaging of the message is as important as the content. Janet: Clinicians working in a busy practice may find it challenging to add discourse measurement and treatment to their treatment plans for persons with aphasia, especially if the measures require a bit of time to administer or score. What advice or suggestions can you give to our listeners about how they can efficiently include discourse measures in assessment and treatment? Jessica: Another measure I have worked on is the Core Lexicon. Here is my message to clinicians: Dear Clinicians: Many researchers are dedicated to working on development of clinically useful discourse measurement. I am proud of recent work we published on utility Main Concept Measurement because it is clinically useful and does not require phonetic transcription. Our checklists and scoring methods are readily available to you. Other resources on discourse analysis available to you are a recent issue of Seminars in Speech and Language; a link in Aphasia Bank; FOCUS: Aphasia (Fostering Quality of Spoken Discourse in Aphasia). If you have questions about a measure and how to use it, do not be shy about reaching out to the authors. Janet: Another area of clinical interest to you has been using transcranial direct current stimulation, or tDCS, as a treatment technique. Here’s a multiple part question for you about tDCS: how does tDCS work; how do you use tDCS in aphasia therapy; and how can it enhance communication skills in a person with aphasia? Jessica: There are long answers to your questions that we could spend hours discussing. Let me give a short answer here. tDCS can modulate your brain; it is called neural stimulation but it is best to think of it as neuromodulation. tDCS does not make neurons fire or stop them from firing but modulates the ‘soup’ within which these neurons are firing. Electrodes are placed on your scalp and electrical current passes through your scalp and through your brain, and influences electrical communication that is already happening between your neurons. In aphasia therapy we pair tDCS with behavioral therapy with the goal of modulating electrical communication between neurons that is already happening during treatment tasks in hopes that you can encourage more involvement of desired brain areas and downplay involvement of less desired brain areas. So far, the most positive effects have been seen with naming treatment. We are in the early stages of pairing tDCS with discourse treatment and have promising results. The work I am doing now combines two areas of research that I love: brain stimulation and discourse, and I am happy to have received a grant to further my work in these areas. Janet: tDCS works together with behavioral treatment. How do you see tDCS fitting into contemporary aphasia treatment to support functional communication and life participation for persons with aphasia? Jessica: I think this technique shows promise and will help reveal untapped recovery potential. For so long we focused on the brain lesion: the site, the size, what it can tell us about what a person can and cannot do. However, the lesion is not a modifiable factor, and the focus should be on things that are modifiable. For example, we have not focused on or had the tools to examine the rest of the brain. What does the health of the rest of the brain tell us about what a person can or cannot do, and how much a person might improve? There are many observations about the rest of the brain that are important and perhaps tell us that these areas are not as intact as we thought. They may have low blood flow or be less connected, and these states may be modifiable. This suggests that we should use every tool available to us to aid recovery, including behavioral treatments, neuromodulation, and variable treatment dosage Using all the techniques available to us will help us push the recovery curve higher and longer, including focus on connected speech, which in turn, helps improve life participation. Janet: That is, as I see it, the heart of LPAA: where does the person with aphasia want to go and what are the pathways that can be used to get there? Certainly, using every tool available to us is important in planning treatment.  Jessica: Yes indeed. A new avenue of investigation for us is remotely supervised tDCS. This project will help us understand both tDCS and remotely supervised behavioral and neuromodulation treatment delivered in the home.   Janet: The pandemic of 2020 has taught us many things, including the value of virtual treatment for individuals, including those who have aphasia. Your work in remotely administered tDCS fits nicely with this changing view of treatment delivery. Your work in aphasia also encompasses several person-centered efforts. Tell us about some of your translational research and clinical projects such as recognizing the efforts of caregivers, examining fidelity in assessment and treatment, creating an aphasia choir, and investigating treatment dosage. Let’s start with your interest in supporting caregivers, what have you discovered? Jessica: First I would say caregivers are grateful to be asked about themselves. They are used to answering questions about their family member and appreciate the focus turned on them. Second, they are tired and want to rest. Third, they are in need of information about how to provide care for someone else, and how to do self-care. We discovered other interesting themes such as depression, quality of life, and fatigue. Addressing these issues is important to life participation because as we all know, life participation is not just about the person with aphasia, it is about the unit in which the person with aphasia lives. Janet: You make excellent points, Jessica. Several years ago my colleagues published a paper asking caregivers what information they had and said they wanted. The data suggested there is a gap between what information we think is being given to caregivers, we as speech-language pathologists and other medical professionals, and what caregivers think they are being given. It is a gap that should be filled. Another area of interest to you is assessment and treatment fidelity. When treatments are modified, sometimes without a clear foundation, it becomes difficult to track if the treatment is being delivered in the same way and that a clinician is being internally consistent. Fidelity in both assessment and treatment is important in assuring the best possible outcome for a patient.  What would you like our listeners to know about your work in fidelity? Jessica: This line of research came about in an interesting way for me, from thinking about it for a grant proposal, leading a roundtable discussion, and now investigating more closely. One thing I would like listeners to know is that it is important when reading a report of clinical treatment research to read carefully to determine that the treatment was carried out with a high degree of fidelity. If it was, then the stud is more likely to be replicated and the results are more believable. Researchers should think about fidelity as they design an assessment or treatment study; adhere to principles of fidelity during the project; and report their fideladventureity results. Clinicians should know that the manuals and operational steps available are important for interpretation. The example I sometimes give is that if one wants to use the results of an assessment procedure, for example to compare to the population listed in the assessment manual, then the assessment should be given exactly as described in the manual. If one has to off script, which certainly happens in a clinical environment, one must make note of those changes and consider that when interpreting the assessment results. The other note I want to make for clinicians is that if one finds oneself frequently making a change to an assessment or treatment protocol to accommodate a patient or situation, then the field needs to know. This is practice-based evidence (PBE), helping authors and researchers know how protocols should be updated or changed so that other people can implement it with greater effectiveness. Fidelity supports hearing more form clinicians through the PBE side instead of just the EBP side (Evidence-based practice). Janet: You are absolutely right, Jessica. Now let me ask you about your aphasia choir. Twelve years ago, I saw one of the first aphasia choirs begin at our site at California State University, East Bay. It was quite an adventure watching the unique choir members with aphasia navigate aphasia and music to become a unified choir. Two years ago, I gleefully (pun intended) watched your NeuroChoir post their first video – what a joy it was. To watch – all of you on the screen and singing away – impressive! Tell me about how your choir evolved and also how it continues to meet, especially in the midst of this pandemic? Jessica: I love our choir. There are so many aphasia choirs and it is great to hear that you were there for one of the first ones. Our choir began in 2016. I have a musical background which made me less fearful to begin and lead a choir than I might have been. We needed something more in our community or people with aphasia and I wanted to help provide that. We welcome people with any type of brain injury, not just aphasia, and although our membership waxes and wanes, we do have a core group of individuals who attend. During the pandemic choir has been a challenge. Singing together in a virtual environment does not work so well because of the audio and visual delay, and logistical issues such as people talking over each other. During our choir time we play musical games and other activities; everyone but the singer is muted; and we certainly long for the days we can meet in person again. Choir is different now, but there is still joy. Janet: In your video, I can see that in your faces and hear it in your voices. Talking with you today is a smorgasbord of mutually interesting topics and a fun discussion of translational research and clinical ideas, and how our worlds have intersected over the years. Moving to another topic of interest to both of us is treatment dosage – how to figure out how to deliver treatment in just the right amount so the result achieved is a positive outcome. That is, not giving too much treatment – more than is needed, or too little to effect an outcome. This is a tricky question with no easy answer. What insights have you learned in your work?    Jessica: This topic kind of hurts my heart, Janet, because we need more. More research into treatment, more treatment hours in a day, more treatment days in a week, better treatment schedules, remote treatment so patients can work at home, more inclusive founding mechanisms, more conversational partners and settings – we just need more. If one looks at the literature on animal learning, which I realize does not always directly apply to humans, we are nowhere near the number of repetitions or hours spent in treatment to produce those amazing results that have hacked into the neuroplastic principles. If we are really wanting to apply neuroplastic principles to research and clinical practice, which we should do, we have to find ways to facilitate this idea of more. At this point I look on this with sadness as there are so many obstacles to doing the “more” part of this. It will be critical in the coming years to get creative as a community to advocate for research into treatment dosage. Janet: I think you right about that. Add into your thinking that individuals are so variable that a dosage one might think appropriate for one person might not be so for another person. I can see how it hurts your heart and there is certainly a long way for us to go to figure out answers, however it is a worthwhile endeavor. Jessica, as you can tell form our conversation today, it has been so much fun to talk to you about our interests and your work. I am impressed with your work and dedication to serving people with aphasia. As we come to a close, what success stories or advice or lessons learned would you like share with clinicians working with people with aphasia using an LPAA model, across your clinical career, y our research career, or just across life in general. Jessica: That is a good one to end on. I would say first, there are lots of tools out there through Aphasia Access and other resources, so many that it may become overwhelming or difficult to navigate. When that happens, reach out – to people, organizations, and any source. The other issue is barriers to using the LPAA model. Sometimes one is in a place where there are barriers to implementing your ideas – I have certainly been there. Sometimes you have to move the barriers and sometimes move yourself to a place where those barriers don’t exist; moving professionally or ideologically. Sometimes however, one o the barriers might be yourself – are you getting in the way of implementing your ideas. I say that from experience as I had to get out of my own way to make progress. The last thing is to plead with clinicians to keep using your voice to advocate for people with aphasia. There are researchers who are clinically minded and they are wanting to listen to you and learn from you – your voice, your experience, your front line work with persons with aphasia, your barriers, and your victories in LPAA. Your voice and your viewpoint are valuable and influential, so please keep raising your voice because it has and will continue to influence the questions being asked in a positive way.   Janet: Thank you Jessica. That was a terrific response and an uplifting way to end our conversation today. It is clear that you have vision for how you would like to address the questions we have been discussing. I feel the enthusiasm coming across the airwaves and I hope our listeners will feel that as well and reach out to you if they have questions or comments. Thank you for your thoughtful responses to my sometimes-perplexing questions. This is Janet Patterson, speaking from the VA in Northern California, and along with Aphasia Access, I would like to thank my valuable guest, Jessica Richardson, for sharing her knowledge, wisdom and experience as a clinician, researcher, and advocate for people with aphasia.  You can find references, links and the Show Notes from today’s podcast interview with Dr. Jessica Richardson at Aphasia Access under the resource tab on the home page. On behalf of Aphasia Access, we thank you for listening to this episode of the Aphasia Access Conversations Podcast. For more information on Aphasia Access and to access our growing library of materials please go to www.aphasiaaccess.org.  If you have an idea for a future podcast topic email us at [email protected]. Thank you again for your ongoing support of Aphasia Access.   Links  Publications: https://www.ncbi.nlm.nih.gov/myncbi/12WPcJZAUeOAR/bibliography/public/ Websites: https://shs.unm.edu/people/faculty/jessica-richardson.html http://www.jdrichslp.com/  YouTube:  https://www.youtube.com/channel/UCTQah61XG76Pt3PIKJvyB0A/playlists