The speech-language pathologist and the patient sit side by side at a table, looking at a flashcard. “What is this?” asks the pathologist as she points to the image on the card. The patient studies it intently, taking in the color, the shape. He closes his eyes. And then the word comes to him: “A brain.”
The SLP then begins to review the sound features of the target word with the participant. For the first sound of “brain,” the patient closes his eyes. “Buh-ray-n. Buh-ray-n,” he whispers. “‘Buh.’ The first sound is ‘buh.’” He taps the table one time, indicating the number of syllables, then comes up with two words that rhyme and identifies the vowel sound.
The activity is one task of the phonological therapy session, and at C-STAR — the University of South Carolina’s Center for the Study of Aphasia Recovery — it’s part of a larger effort to better understand stroke recovery.
Aphasia is a language disorder that occurs after damage to certain areas of the brain. Nearly 180,000 Americans acquire it each year, according to the National Aphasia Association, and most of those cases are the result of stroke. It is especially prevalent in South Carolina, which has the fifth highest stroke death rate in the nation.
But survival is not the same as recovery. A third of stroke survivors develop aphasia. While some recover fully, most continue to experience aphasia to some degree. That’s where treatment can help.
“We know now that in general it has a positive effect on outcomes, particularly communication,” says Dirk den Ouden, an associate professor in the Arnold School of Public Health’s Department of Communication Sciences and Disorders. “It's really hard to measure quality of life, but we know that therapy works. What we didn't know is why it doesn't work for everybody.”
That was one of the first questions the center’s researchers hoped to answer when it was founded in 2016. After receiving an $11.2 million center grant from the National Institutes of Health, Julius Fridriksson — a communication sciences and disorders professor who now serves as the university’s Vice President for Research — launched a series of research projects to better understand aphasia and improve quality of life for stroke survivors.
One of those projects, now led by Den Ouden, compared two types of aphasia therapy — semantic and phonological — to identify the factors that can predict individual response. Essentially, who is most likely to improve with therapy and how can that therapy be tailored to maximize a patient’s recovery?
To answer that, the team looked at participants’ brain structure and brain functioning, and they conducted cognitive and language testing before treatment. As they continue analyzing the data and publishing their findings, they’ve already found a number of predictors, including age at stroke and lifestyle factors such as happiness and social activities. Another predictor is brain age — an assessment calculated by machine learning that looks at how someone’s brain scan compares to others of the same age.
“The fact that something so subtle as the brain age can actually predict response to treatment and someone’s recovery path — that is surprising,” Den Ouden says. “It's not counterintuitive, but it's surprising that the measurements are so good that we can actually show that.”
The second phase of the project, which began two years ago, will examine how telehealth affects treatment outcomes. If telerehabilitation is found to be comparable to in-person therapy, it could open the door to more affordable treatments. It also has implications for people who live in rural areas and can’t travel an hour to see the nearest speech-language pathologist. And with many providers switching to telehealth post-pandemic, a study to assess its effectiveness is timely.
"A really important part of our work is to make the public aware that this is not a deficit in intelligence. Most people with aphasia would tell you how frustrating it is that they're not seen as whole in society. If you have trouble communicating, you're left out, and you really have to do a lot of work yourself to get back in."
“Again, we do a whole battery of testing beforehand because we also expect that for some people it may work, but not for everybody,” Den Ouden says. “We're really interested in understanding the factors that predict whether telerehabilitation works for an individual.”
While research is central to the center’s work, the staff and researchers are also heavily involved in aphasia advocacy and outreach. More than 80 percent of people have never heard the term “aphasia,” according to the National Aphasia Association, and nearly one-third believe speech difficulties are associated with intellectual deficiencies.
“A really important part of our work is to make the public aware that this is not a deficit in intelligence,” Den Ouden says. “Most people with aphasia would tell you how frustrating it is that they're not seen as whole in society. If you have trouble communicating, you're left out, and you really have to do a lot of work yourself to get back in.”
On the outreach side, the team at C-STAR organizes activities throughout the year: monthly “lunch bunch” gatherings at local restaurants, virtual and in-person support groups, a drama group, an annual community event, participation in the annual Advocacy Day for Access and Independence at the State House.
“A lot of what we do here is not just treatment,” says C-STAR research associate Sara Sayers, who manages the aphasia lab and helps plan activities.
She’s seen study participants develop friendships and find a sense of community through the outreach activities and events.
“Being able to socialize with others along with our treatment makes such a difference in their confidence,” Sayers says. “It’s wonderful to see participants deciding to go out and do activities that are meaningful to them that they haven't been doing since before their stroke.”
That matters because maintaining a healthy social life and having a strong support system are two predictors for how someone will respond to aphasia treatment. But hope is also a critical part of the recovery process, which is why Den Ouden emphasizes that predictors reflect a group average, not an individual person’s capabilities.
“We see people in the lab who've had a stroke 10 years ago,” he says, “They come to our studies to work on a specific aspect: focus, drill, train, persevere. And they get better in that skill. Not 100 percent, but more than they were. So, it's all little steps. And this question — how far can someone get? — that is part of our research.”