PICTURE-IT: a pilot randomized cross-over trial encouraging right-hemisphere engagement for the treatment of aphasia via telemedicine.

Background: Prior studies have highlighted the importance of the right hemisphere in recovery from aphasia due to left hemisphere stroke. In particular, the right hemisphere homologous language network appears to support subacute (and sometimes chronic) recovery for many patients. We developed a telemedicine-delivered therapy that engages diverse right hemisphere-dominant skills to target nouns and verbs within utterances, Producing Increasingly Complex Themes Using Right-hemisphere Engagement - Implemented with Telemedicine "PICTURE-IT". Aims: This randomized crossover pilot study was designed to examine the feasibility of the PICTURE-IT therapy and determine whether some participants improve more with PICTURE-IT compared to an established telemedicine approach that targets lexical skills. Methods & Procedures: Seventeen adult English-speaking participants with subacute (1-4 months) or chronic (over 6 months) aphasia who continued to experience naming deficits as measured on the Boston Naming Test or Hopkins Assessment of Naming Actions were included. Participants received fifteen 45-minute sessions of each therapy approach, followed by a washout period. Three participants withdrew due to worsening medical circumstances unrelated to therapy. Participants' naming and discourse were assessed at baseline and one week after each therapy block. As the pilot had a modest number of participants, each participant's trajectory was examined separately in order to consider how individual differences may play a role in therapy benefit. After the trial, participants were asked to complete a brief survey rating the PICTURE-IT approach and the established approach in their enjoyableness and utility. Outcomes & Results: Both treatments were effectively administered remotely throughout the trial. Fisher's Exact tests contrasting the improvements provided by each therapy approach were not significant for any individual, nor were there significant differences in the proportion of people who experienced more benefit from one approach or the other relative to their time since stroke (sub-acute versus chronic). Conclusions: Although average improvements in communication skills were similar across treatments, order, and subacute vs chronic, individuals often responded better to one therapeutic approach or the other. Future studies will build upon these preliminary observations of effectiveness and identify reasons participants respond better to one treatment or the other.