Understanding the Mechanisms of Change and Optimal Parameters in Conversation Treatment for Aphasia

失语症是一种影响大约200万美国人的语言障碍。与失语症相关的沟通障碍限制了恢复工作和爱好的能力，恶化了社会关系，并导致社会孤立。社会孤立与许多负面健康结果相关，包括死亡率。因此，失语症的后果可能是广泛而严重的。集体治疗有可能改善沟通和减少社会孤立，同时还能降低医疗费用。然而，这种治疗形式缺乏强有力的证据基础。本研究采用假设驱动的方法来检验对话治疗的效果，并发展和完善对话治疗如何导致沟通能力行为改变的机制途径。我们将系统地探讨治疗效果是否因参与者数量（大组或双组）、组组成（异质性与同质性失语症）和失语症严重程度而不同。该研究将在三个地点共招募168名失语症患者。在第一个周期中，72名参与者将被随机分配到三种情况中的一种：双组治疗、传统组治疗或延迟对照组。在第二和第三个周期中，48名重度失语症患者和48名轻度至中度失语症患者将被随机分配到大组或双组。在所有周期中，治疗将进行60分钟，每周两次，持续10周。在治疗过程中，语言病理学家将使用个性化的、语言的和多模态的线索层次，促进对一系列突出主题（如当前事件）的讨论。主要结果测量是沟通的功能测量（Aphasia communication outcome measure， ACOM; Hula et al., 2015）。次要结果测量将包括标准化测试和患者报告的结果测量，并检查语言和功能性沟通能力。所有参与者将在治疗前、治疗后、治疗后4周和治疗后12周进行评估。拟议的研究将涉及以下具体目标。具体目标1是检查与延迟治疗对照组相比，在二组和大组中进行谈话治疗的效果。具体目标2是通过测试治疗效果是否随失语严重程度（2A）或组组成（2B）的不同而不同，来确定对话治疗的最佳参数。具体目标3将测试对话治疗影响行为改变途径的假设模型。研究结果将为对话治疗提供进一步的疗效，并告知这种干预的最佳参数和结果。这项工作为阐明谈话小组治疗的变化机制迈出了至关重要的第一步，其长期目标是确保失语症患者获得具有成本效益的护理。

Aphasia is a language disorder that affects approximately two million Americans. The communication barriers associated with aphasia limit the ability to return to work and hobbies, worsen social relationships, and lead to social isolation. Social isolation is correlated with many negative health outcomes, including mortality. As a result, the consequences of aphasia can be wide reaching and severe. Group treatment has the potential to improve communication and reduce social isolation, while also reducing medical costs. However, this treatment format lacks a strong evidence base. This research uses a hypothesis-driven approach to test the efficacy of conversation treatment and develop and refine a mechanistic pathway of how conversation treatment leads to behavioral changes in communication ability. We will systematically explore whether the effects of treatment differ as a result of number of participants (large group or dyad), group composition (heterogenous versus homogenous profiles of aphasia), and severity of aphasia. The study will enroll a total of 168 participants with aphasia across three sites. In cycle one, 72 participants will be randomly assigned to one of three conditions: dyad treatment, traditional group treatment or delayed control group. In cycles two and three, 48 participants with severe aphasia and 48 participants with mild-moderate aphasia will be randomly assigned to either large group or dyad conditions. In all cycles, treatment will occur for 60 minutes, twice per week for 10 weeks. During treatment sessions, a speech pathologist will facilitate discourse on a focused set of salient topics, such as current events, using individualized, linguistic and multimodal cueing hierarchies. The primary outcome measure is a functional measure of communication (Aphasia Communication Outcome Measure, ACOM; Hula et al., 2015). Secondary outcome measures will include standardized tests and patient reported outcome measures, and examine linguistic and functional communication abilities. All participants will be assessed pre-, post-, 4 weeks post- and 12 weeks post-treatment. The proposed research will address the following specific aims. Specific Aim 1 is to examine efficacy of conversation treatment delivered in dyads and large groups compared to a delayed-treatment control group. Specific Aim 2 is to determine optimal parameters for conversation treatment by testing whether the treatment effects differ as a function of aphasia severity (2A) or group composition (2B). Specific Aim 3 will test a hypothesized model of the pathway by which conversation treatment effects behavioral change. The results will provide further efficacy for conversation treatment and inform about the optimal parameters and outcomes of this intervention. This work takes a vital first step towards elucidating the mechanisms of change in conversation group treatment, with a long-term goal of ensuring access to cost-effective care for people with aphasia.