Can Non Linguistic Cognitive Stimulation Enhance The Cognitive and Linguistic Functions of People With Aphasia Receiving Conversation Therapy

Aphasiology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/paph20
Can non-linguistic cognitive stimulation enhance

the cognitive and linguistic functions of people
with aphasia receiving conversation therapy?
Preliminary findings
Winsy Wing-Sze Wong & Sam Po Law
To cite this article: Winsy Wing-Sze Wong & Sam Po Law (2022): Can non-linguistic
cognitive stimulation enhance the cognitive and linguistic functions of people with
aphasia receiving conversation therapy? Preliminary findings, Aphasiology, DOI:
10.1080/02687038.2022.2096873
To link to this article: https://doi.org/10.1080/02687038.2022.2096873
Published online: 08 Jul 2022.
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APHASIOLOGY
https://doi.org/10.1080/02687038.2022.2096873
Can non-linguistic cognitive stimulation enhance the

cognitive and linguistic functions of people with aphasia
receiving conversation therapy? Preliminary findings
Winsy Wing-Sze Wong and Sam Po Law
Unit of Human Communication, Development, and Information Sciences, Faculty of Education, University of
Hong Kong, Hong Kong SAR, China
ABSTRACT KEYWORDS
Background: Non-linguistic cognitive deficits, which are common Functional communication;
in people with aphasia (PWA), have been found to predict language conversation therapy;
treatment gains, particularly in naming therapy. Interventions for cognitive function; cognitive
cognitive impairments and their potential benefits to language stimulation
functioning have been explored via principles based on cognitive
training and rehabilitation with mixed results. However, the effects
of cognitive stimulation, which has been widely adopted in people
with dementia, have not been explored in PWA.
Aims: This preliminary study aimed to investigate the effects of
non-linguistic cognitive stimulation on cognitive functions of PWA
and/or outcomes of language treatment. It was hypothesized that
cognitive stimulation utilizing non-linguistic materials might
enhance the cognitive abilities of PWA, and such improvements
might augment treatment gains in functional communication of
PWA who received conversation therapy concurrently.
Methods & Procedures: Forty-seven Cantonese-speaking PWA
received either conversation therapy and cognitive stimulation or
conversation therapy alone. Language outcomes included the
number of main concepts produced by PWA spontaneously during
narration based on wordless comic strips and video-taped stories to
a communication partner. A procedural description task served as
the control task. Cognitive treatment outcomes were defined by
two cognitive factors extracted from principal component analysis
of a cognitive battery tapping attention, short-term/working mem
ory and EF, identified as simple attention and memory (Factor 1)
and executive functions (Factor 2) in a recent study (Wong & Law,
2022). Linear mixed effects (LME) modeling was carried out with
cognitive and language outcomes as dependent variables while
treatment condition and timepoint as fixed factors.
Outcomes & Results: Contrary to expectation, participants in both
treatment conditions improved in cognitive and language out
comes to a similar extent immediately post-treatment.
Maintenance of treatment gains in both functional communication
and EF was present in both groups 8-week post treatment but not
in tasks reflecting simple attention and memory. No change was
observed in the language control task.
CONTACT Winsy Wing-Sze Wong (Ph.D) winsywg@gmail.com Unit of Human Communication, Development,
and Information Science, Faculty of Education, The University of Hong Kong, Pokfulam, Hong Kong SAR.
© 2022 Informa UK Limited, trading as Taylor & Francis Group
2 W. W. WONG AND S. P. LAW
Conclusions: Based on the preliminary findings, improvements in

cognitive and linguistic performances are attributed to the meta-
cognitive, explicit, goal-directed, interactive and naturalistic nature
of conversation therapy. Meanwhile, the null effect of cognitive
stimulation might be related to the differences in the training
materials used, as well as the neuropathology of people with stroke
versus people with dementia, and hence their differential respon
siveness to the cognitive intervention.
Introduction
The comorbidity of acquired language impairments and deficits to cognitive domains
including attention, short-term memory/working memory (STM/WM), and executive func
tions (EF) has been well documented (e.g., Fonseca et al., 2017; Fonseca et al., 2019). The
roles of these cognitive components in relation to the performance of language proces
sing in people with aphasia (PWA) at lexical (Murray et al., 1997; Martin & Allen, 2008),
sentence (Martin & Allen, 2008, Kuzmina & Weekes, 2017, Varkanitsa & Caplan, 2018), and
discourse levels (Frankel et al., 2007; Cahana-Amitay & Jenkins, 2018) have been investi
gated. Our recent report (Wong & Law, 2022) specifically investigated the differential
relation between EF and multi-level linguistic processing of PWA, in which a stronger
connection has been found in more complex linguistic tasks. More importantly, some of
the cognitive components, such as EF and WM, are found to be predictors for treatment
gains and maintenance in many studies targeting naming therapy (e.g., O. Yeung & Law,
2010; Harnish & Lundine, 2015; Simic et al., 2019a; Simic et al., 2019b) and in at least one
report concerning treatment outcomes of functional communication (M. Nicholas &
Connor, 2017). In light of the importance of cognitive functioning in language rehabilita
tion among PWA, it is sensible to consider the potential benefits that cognitive interven
tion may bring to language performance of PWA, in the hope that improvements in the
former may benefit the outcomes of the latter. Indeed, some previous studies have
explored such a possibility with mixed findings.
A detailed examination of cognitive intervention protocols of these preliminary
attempts at language rehabilitation of PWA has revealed that they fall into the approaches
of cognitive training and cognitive rehabilitation, based on the classification proposed by
Clare and Woods (2004). The former approach has been employed for improving atten
tion (Sohlberg & Mateer, 1986; Sohlberg & Mateer, 2001; Sohlberg & Mateer, 2013) via
drill-based tasks with increasing level of difficulty, with inconclusive effects on language
comprehension (Helm-Estabrooks et al., 2000) and discourse production of people with
traumatic brain injury (Murray et al., 2006) in case series. Other studies adopting cognitive
training focused on verbal STM/WM via word/sentence lists repetition or recognition
(Zakriás et al., 2018a; Zakriás et al., 2018b). Likewise, mixed outcomes were observed
(Zakariás et al., 2019), possibly due to a number of methodological limitations (Majerus,
2018). In contrast, cognitive rehabilitation entails systematic training in functional con
texts by ‘(1) re-establishing or strengthening previously learned patterns of behavior or (2)
establishing new patterns of cognitive activity or compensatory mechanisms for impaired
neurological systems’ (Novakovic-Agopians &Abrams, 2014, pp. 824). The feasibility of
APHASIOLOGY 3
incorporating metacognitive strategy training into traditional language therapy has been
examined in case studies with positive outcomes in functional communication (Mayer
et al., 2017), or in both functional communication and verbal cognitive flexibility in some
of the participants (Spitzer et al., 2021) but not in nonverbal EF measured by Wisconsin
Card Sorting Test (WCST; Grant & Berg, 1993).
Although previous findings have shown that the incorporation of principles of cogni
tive training and rehabilitation in aphasia rehabilitation is feasible and may have bene
ficial outcomes, this line of research remains at the preliminary stage and the evidence is
far from compelling. Most of these studies are case studies without control participants or
control tasks. As such it is hard to determine if the improvements are treatment specific.
Besides, only one cognitive domain (e.g., attention or working memory) was evaluated in
most reports; the interplay among various cognitive functions and language processing
throughout treatment remains poorly understood.
Apart from cognitive training and rehabilitation, cognitive stimulation (CS), defined as
“a range of activities and discussions (usually in a group) aimed at general enhancement
of cognitive and social functioning” (Clare & Woods, 2004, pp. 3) and offers “exposure to
generalized cognitive activities rather than training in a specific modality” (Woods et al.,
2012, pp. 4), is yet to apply to rehabilitation of PWA. Its benefits to general cognitive
functioning of people with dementia have been highlighted in a Cochrane systematic
review (Woods et al., 2012), as reflected in test scores of the Mini Mental State Examination
(Folstein et al., 1975) and the Alzheimer’s Disease Assessment Scale – Cognitive (Rosen
et al., 1984). Furthermore, CS is the only approach recommended by the World Health
Organization (WHO) for community-level interventions in managing cognitive declines for
elderly people with cognitive decline impairment or early stage of dementia (WHO, 2017).
Neither cognitive training nor rehabilitation are recommended in the guidelines, due to
insufficient evidence.
Proposal of the current study and methodological considerations

It is well recognized that people with dementia (PWD) and PWA are entirely different
clinical populations in terms of medical etiologies, course of development, signs and
symptoms, as well as prognosis. However, both patient populations do exhibit linguistic
impairments and difficulties in communication, as well as deficits in nonverbal cognition.
Given its strong evidence obtained from PWD, and the close relation between cognition
and language processing found in PWA, it is not unreasonable to expect that cognitive
functioning of PWA may likewise benefit from CS. The current study attempted to
investigate whether non-linguistic CS would enhance cognitive performance of PWA
and/or language outcomes in PWA. If improvement in both cognitive processing and
language performance are indeed observed as a result of non-linguistic CS, this would be
consistent with the view that improved cognitive processing may support successful
language therapy.
In designing the current treatment study, several methodological issues were consid
ered. As mentioned earlier, most previous studies only focused on a single cognitive
domain and its relation to language rehabilitation of PWA. Even in studies of PWD
targeting multiple cognitive components, comparisons were made on every cognitive
task corresponding to certain cognitive functions before and after treatment (Hall et al.,
2013; Spector et al., 2010). Any conclusions about the efficacy of a treatment protocol on
specific cognitive functions may be affected by the inconsistent interpretations regarding
the nature of the cognitive task(s). For example, one may conceive a test tapping
attention switching as a complex attention task, while the test can also be recognized
as an EF measure. This inconsistency in test categorization is further complicated by the
‘task impurity’ problem (Friedman & Miyake, 2017). The present study handled the issue
via a data-driven approach by grouping cognitive tests via principal component analysis
(PCA). Tests with similar nature would be represented under the same factor with different
loadings. This method has been used in a recent study exploring the relation between
multi-cognitive functions and multi-level linguistic processing of PWA (Wong & Law,
2022). It is believed that such a data treatment method may better differentiate the
effects of CS on different cognitive functions of PWA.
Another consideration concerned the nature of materials used in CS and expected
output from the participants. While a number of CS protocols, e.g., Cognitive Stimulation
Therapy (CST; Spector et al., 2003), has used both verbal and nonverbal materials in
training and often required verbal output (such as naming, commenting or retell of
events) from participants, some other protocols utilized nonverbal materials resulting in
positive outcomes on components of cognition (Cheung et al., 2019). In the current
treatment protocol, only non-linguistic materials were employed, and responses from
the PWA were also nonverbal. The arrangement was justified because the use of object
pictures, numbers, colors, shapes, etc. could help minimize the influence of linguistic
demand, so that PWA with difficulties in auditory or written comprehension could
participate in the activities with relatively little support. Moreover, greater reliance/
demand on non-verbal output could avoid any unintended additional language stimula
tion which might bias against participants receiving language treatment alone.
Nonetheless, participants were not prohibited from making verbal responses throughout
training.
In terms of treatment protocol for language intervention, a therapy targeting conver
sation was chosen due to two main reasons. Firstly, the ability to engage in a conversation
is considered linguistically and cognitively demanding (Barker et al., 2020). Our recent
report (Wong & Law, 2022) also suggested that the role of EF became more prominent in
tasks with more complex linguistic level (monologic discourse production) than simpler
ones (picture naming of objects and action verbs). Among different treatment protocols
of conversation therapy (CT; Simmons-Machie et al., 2014), conversation coaching,
a dyadic protocol involving both the PWA and a communication partner during training,
was adopted with modifications detailed under the section ‘Materials and Method’. Its
effectiveness was described in Hopper et al. (1999, 2002) in terms of the number of main
concepts communicated about each event, and the benefit reflected in Communication
Activities of Daily Living – 2 (CADL – 2; Holland et al., 1999). Given the close relationship
between EF and symptoms manifested in conversation (Frankel et al., 2007; Wong & Law,
2021) and the significance of EF in rehabilitation of functional communication, it was
expected that PWA would show greater improvement in communication success if
enhancement in EF was present due to CST. Secondly, the ability to take part in
a conversation is an important functional communication skill in daily lives. The need to
restore such skills is strongly advocated by the Life Participation Approach to Aphasia
(LPAA; Chapey et al., 2000). In light of questionable generalization effects of naming
APHASIOLOGY 5
therapy to everyday communication of PWA (e.g., Palmer et al., 2019, Kristensson et al.,
2022), therapies aiming at improving functional communication of PWA deserve further
investigation. In addition, the sample size of the present study allowed us to statistically
analyze possible impact of receptive ability and fluency type of PWA on treatment out
comes, which were not taken into consideration in previous studies of conversation
therapy.
Materials and method

Study design and schedule
A controlled, non-randomized, pre-/post-comparison design was adopted. Participants
were assigned to either the conversation therapy plus cognitive stimulation ‘CT + CS’ or
the ‘CT’ group. Participants receiving either treatment would undergo the same assess
ment schedule illustrated in Figure 1. Pre-treatment assessments were carried out in the
first and fourth weeks with all the language and cognitive tasks described in subsequent
sections; three more assessments were conducted in the 8th, 12th and 20th week, corre
sponding to the performance of PWA in the middle of the treatment block, immediate
post-treatment and eight-week post-treatment, respectively. The study was registered
retrospectively and listed on the ISRCTN registry with study ID ISRCTN19176792.
Participants
Fifty-three PWA were recruited in the community from May 2018 to May 2019 at
various rehabilitation centers across Hong Kong. The project was approved by
Human Research Ethics Committee of the University of Hong Kong (reference num
ber: EA1805002). Inclusion criteria included: 1) native speakers of Cantonese, 2)
chronic aphasia with onset more than 6 months, 3) no reported progressive neuro
genic etiologies (e.g., dementia, Parkinson’s Disease), 4) no motor speech disorders of
moderate to severe level, and 5) no reported hearing and visual impairments. The
Figure 1. Timeframe of assessment and Treatment.

majority of the PWA (48 out of 53) were monolingual Cantonese-speakers. No

concurrent speech or cognitive therapy provided by other institutions were received
during the study period. Written informed consent detailing the purpose of the
study, treatment assignment, and the experimental procedures was obtained from
the PWA and their caretakers, if available. Screening and informed consent were
implemented by the first author or trained speech therapists. Participants were
assigned to one of the treatment conditions, i.e., ‘CT + CS’ or ‘CT’. Treatment assign
ment was non-randomized. It was based on both the time when a participant was
recruited and their availability to attend a certain treatment condition.
Forty-seven of the participants completed the treatment. One of the participants from
the ‘CT + CS’ treatment group did not finish treatment due to physical illness. Two PWA
from the ‘CT’ treatment group withdrew from treatment while another three participants
did not receive treatment due to their unavailability in the treatment period. The total
numbers of fluent and non-fluent PWA were 22 and 25, respectively. The demographic
information and fluency type of the PWA are accessible via an online repository1. As shown
in Table 1, the two treatment groups did not differ in demographic characteristics including
age, gender, years of education received, fluency type, and post-onset time. The number of
treatment sessions received was comparable between the two treatment conditions.
During CT and measurement of language outcomes, communication partners were
involved. Eighteen of them (38.3%) were family members of the PWA while the rest
(61.7%) were volunteers recruited from local universities or community. The volunteers
were informed about the treatment aims and their roles in the study. Each volunteer was
assigned to form a dyad with a PWA participant whose family members/caretakers were
not available to participate in the therapy.
Experimenters involved in the assessment and training included the first author,
speech therapists, as well as speech therapy students of the University of Hong Kong.
Students with prior clinical experience working with a neurogenic population were
recruited. All experimenters had attended a training workshop held by the first author,
a certified trainer of CST, with procedures of assessment and treatment explained in detail
and supplemented with a training manual. Regular monitoring of speech therapy stu
dents by either the first author or speech therapists with prior experience in conducting
assessment and treatment of adult language disorders was carried out to ensure that the
procedures were implemented as planned.
Table 1. Characteristics of PWA Who Completed Treatment Study.

CT + CS CT t-test (df)
Number of participants, n 24 23
Age (years), mean ± SD 56.6 ± 9.7 56.6 ± 9.8 .17 (45), p = .87
Gender, n (%)
Male 14 (58.3) 14 (60.9)
Female 10 (41.7) 9 (39.1)
Year of education (years), mean ± SD 9.8 ± 3.7 10.2 ± 4.6 .39 (45), p = .70
Time post onset (months), mean ± SD 36.2 ± 28.1 51.2 ± 43.2 -1.42 (45), p = .16
Number of fluent/ non-fluent speakers 13/ 11 9/ 14
Number of treatment session received ± SD 11.8 ± 0.7 11.8 ± 0.9 .15 (45), p = .89
Note. CT + CS = Conversation therapy plus cognitive stimulation; CT = Conversation therapy.
APHASIOLOGY 7
Language assessment and outcomes

Language outcomes included three story probes that tapped PWA’s ability in
a conversation, in which they tried to convey the content based on short stories depicted
in comics and short videos with a communication partner who were naïve to the content.
One four-panel and one six-panel comics from the ‘Old Master Q’, a comic series widely
known in the local community, together with a short video depicting the origin of
a Chinese idiom, were included as story probes. A sample of comic strip is available on
the online repository mentioned in Footnote 1. The procedures were adopted from
a previous study (Ramsberger & Rende, 2002). Specifically, members of the dyad (i.e.,
PWA and their non-aphasic communication partner) were informed that the participant
with aphasia had to converse with their partner about the picture sequence and video-
based story s/he had just read/watched so that the communication partner would be able
to re-tell the content of the picture sequence or story. Pictures depicting two of the main
characters of the Old Master Q, together with a pen and piece of paper were provided,
and the dyad was told to exchange ideas by any means. No further instructions were
given by the experimenter and no time limit was set for the conversation. The whole
process of communication exchanges between members of the dyad was videotaped and
was orthographically transcribed for further analysis.
Scoring criteria was based on main concept (MC) analysis (L. E. Nicholas & Brookshire,
1995), an outcome measure applied in studies on conversation coaching. While the
treatment outcome in Hopper et al. (2002) was defined by the number of MC co-
constructed by the dyad, the current study only considered total MC scores produced
by PWA alone, as such the outcome measure might better reflect the changes brought
about by treatment. It was defined by the MCs produced by the PWA during the
interaction with the communication partner without explicit cueing given by the partner.
Spontaneous production or other verbal output followed by non-specific prompting or
response from the partner such as ‘Okay, then what’s next?’, ‘What happened next?’ were
then scored. However, if the communication partner asked specific questions like yes/no
or binary choice questions, or prompts that requested specific answers including ‘Where
did the man go?’, ‘what did he feel?’, the answers would not be given credits. Percentage
scores obtained by the PWA in each of the probes were used, based on the normative MC
lists (Chan, 2018; T. Y. Yeung, 2018).
A language control task of procedural description of how to prepare an egg and
ham sandwich was conducted to evaluate treatment-specific effects. Such a task was
chosen due to its significant difference from a conversation in terms of the discourse
genre each belonged to, presence of interaction between the speaker and the
listener (i.e., monologic vs. dialogic), and the macro-structure and content narrated.
The task procedure followed that described in the Cantonese Aphasia Bank (Kong
et al., 2011). A photo showing slices of bread, ham and eggs was presented to the
participants. They were then asked to verbally describe the procedures involved in
making the sandwich in as much detail as possible while the stimulus remained in
sight. PWA’s performance were converted into z-scores based on normative perfor
mance of Cantonese speakers (Fung et al., 2017).
It is reasonable to believe that one’s receptive ability might affect their performance in
engaging in a conversation. To prevent it from confounding with the present investiga
tion, sentence comprehension was monitored throughout the study period via
a sentence-picture matching task (Law & Leung, 1998) comprising of semantically rever
sible and non-reversible active and passive sentences, as well as canonical and noncano
nical subject or object relative clause sentences. Owing to the ceiling performance of
healthy individuals reported in Law and Leung (1998), raw scores of the PWA on the
sentence comprehension task were used.
Cognitive assessment and outcomes

Cognitive performances were defined by the two cognitive factors extracted from PCA
reported in Wong & Law (2022), which were based on a series of tasks assessing attention,
STM/WM, and EF. One of the cognitive factors (Factor 1) was taken to reflect performance
on simple attention and STM/WM, whereas the other (Factor 2) represented one’s ability
in EF. Table 2 illustrates the loadings of the constituent cognitive tasks on each of the
cognitive factors. Details of the assessment tasks and extraction of cognitive factors are
reported in Wong and Law (2022).
All of the above language and cognitive measures were administered throughout the
course of treatment based on the schedule illustrated in Figure 1.
Language treatment
All PWA received a total of 12 one-hour language treatment carried out twice a week.
Treatment protocol was adapted from the procedures described in Hopper et al. (2002)
with some modifications. Given the limitations in resources available and time constraint,
the instructional session included in the original protocol in which the dyad and the
clinician watched the pre-treatment story probing video together and discussed the
communication strategies was not implemented. Instead, the strategies were explained
to the dyad at the beginning of the language treatment session. Some examples of the
strategies are included in Table 3. Another modification concerned the contexts in which
Table 2. Principal Component Loadings from

Cognitive Tests with Varimax Rotation.
Cognitive Tests Factor 1 Factor 2
Digit Span Forward .8809* .2867
Digit Span Backward .7110* .4561*
TEA 1 (MS) .7918* .0700
TEA 3 (ECD) .7805* .0152
TONI-3 .0629 .8330*
WCST .1839 .7860*
Note. Factor 1 = Simple attention and memory; Factor 2 = EF.
TEA 1 (MS) = Test of Everyday Attention (Map Search); TEA 3
(ECD) = Test of Everyday Attention (Elevator counting with
distraction); TONI-3 = Test of Nonverbal Intelligence-third
edition; WCST = Wisconsin Card Sort Test
* Indicates the test was included in subsequent calculation of
individual scores for each extracted factor.
APHASIOLOGY 9
Table 3. Examples of Communication Strategies for PWA and Communication Partners for
Conversation Therapy.
For PWA For communication partners
(1) Use of multi-modal means for expression, such as drawing, (1) Repeating keywords produced by PWA via multi-
gesturing. modal means to verify the accuracy of message.
(2) Description of semantic features related to target when (2) Remind PWA to use multi-modal means of
word-finding difficulties occur. expression in incidences of word-finding
difficulties.
(3) Production of 2-to-3-term utterances (e.g., Subject-verb or (3) Indicate clearly to the PWA when communication
subject-verb-object) for more complete idea formation. breakdown occurs.
the strategies were practiced. To facilitate the acquisition of the strategies and their use in
narrating stories, pictures depicting single objects or action verbs were used during the
first half of the training session (i.e., 30 minutes) in the first treatment phase (i.e., sessions
1-6), so that the dyad could practice the strategies in a simpler context. Pictured objects or
action verbs were shown to the PWA only and the dyad had to utilize the suggested
tactics to communicate if the PWA encountered problems in describing the content of the
picture. In the second half of these treatment sessions, comics from Old Master Q, which
were not used as story probes in the assessment, were adopted as training materials.
When training proceeded to the second phase (i.e., 7th to 12th sessions), pictures of object
or action verbs were no longer used and were replaced by short videos depicting origins
of Chinese idioms. Each video lasted about three minutes. The stories illustrated in the
videos were considered more complicated as the plot might involve more characters and
episodes. The video could be shown to the PWA for a second time upon request.
Training procedures in narrating comics or short videos were similar to those used
in story probing in assessment. Additional support given during training include
presentation of a cue card with communication strategies for the dyad, as well as
a chart illustrating the story grammar elements (i.e., setting, initiating event, plan/
reaction, resolution, internal response) so the dyad was better informed about the
focus of information exchange in formulating a story. During training, they tried to
work out the content of the story using the above support upon clinician’s demon
stration and cueing. The clinician intervened in the conversation where communica
tion breakdowns could not be repaired by the dyad, or when strategies were
inadequately applied by either member of the dyad. The training process was audio-
taped for fidelity checks.
Cognitive stimulation
PWA assigned to the ‘CT + CS’ treatment condition received a one-hour session of CS
when they attended ‘CT’. The sequence of receiving CS and CT changed in every other
session. In the meanwhile, no additional intervention was given to the participants
belonging to the ‘CT’ group. They returned to their routine activities after language
therapy. Participants who received therapy at rehabilitation centers resumed their physio-
or occupational therapy while those with language therapy conducted at home contin
ued their daily routine such as watching television or going out for a walk.
Cognitive-stimulating activities were provided in groups with each comprising 3-4 parti
cipants. Grouping of participants was dependent on their availability and thus the abilities of
the PWA in cognition and language might vary. In each session, the participants took part in
three group activities in which various cognitive skills were required. Some of the activities
were adapted from a series of game-based activities for Chinese elderly developed by the
Jockey Club Center for Positive Ageing (JCCPA; 2008, 2009, 2012), in which the activities were
designed in accordance with principles of CS. Activities that used linguistic materials were
replaced with non-linguistic stimuli, e.g., in a card searching game written words were
replaced by numbers or shapes so that the procedures and cognitive components involved
remained highly similar to the original version. Other activities employed materials borrowed
from the toy library for the elderly hosted by the Hong Kong Lutheran Social Service.
Tabletop games including board games, card games and dice games, which were mentally
engaging and culturally appropriate for Chinese adults, were borrowed free of charge.
Finally, some tabletop competitions that involved physical movement/fine-motor coordina
tion including air hockey, mini-curling, and domino stacking were also introduced.
Depending on the performance of the PWA, the level of difficulty of the activities could
be varied by applying more complex rules or by timing the task. In sum, the activities were of
different cognitive demands, and each may tap one or more cognitive components with the
use of multi-modal sensory input. Examples of activities and the cognitive components
involved, as given in the activity books of JCCPA, are provided in Table 4.
During CS, each group was monitored by a group manager – who was either a speech
therapist or a trained student speech therapist. The role of the group manager was to
facilitate PWA’s performance throughout the training, including task explanation and
demonstration, judging the response of the participants and provision of cueing when
necessary. However, the group manager did not give explicit instructions or explanation
about the use of strategy, as the nature of the activities was to enhance stimulation but
not to train skills or strategies.
Data Analysis
Comparison of treatment effects on cognitive and language outcomes between
treatment conditions
Firstly, the baseline performance of the PWA on the language tasks and cognitive
components (in terms of factors resulted from PCA) were compared between the two
treatment groups and between the two baseline timepoints. Mixed ANOVAs with treat
ment condition (‘CT + CS’ vs. ‘CT’) and timepoint of baseline testing (first vs. second
baseline testing), as well as the interaction effect, were carried out to investigate if the
PWA of the two treatment conditions were comparable in baseline language and cogni
tive performance across repeated testing.
Secondly, the effects of treatment on cognitive and language performance were
investigated using mixed effects model (MEM). MEM, also known as multilevel linear
model, has several advantages over more traditional statistical tests such as
repeated-measures analysis of variance (RM-ANOVA) and t test for studies with
repeated design. It examines how the performance of each of the participant
changes over time by taking into consideration the between-individual heterogeneity
in the variables of interest. Random effects are added to each individual participant,
Table 4. Examples of Non-verbal Cognition-stimulating Activities.
Name/title of Procedures Cognitive functions being stimulated
activity
Dim-sum The game set was developed by the toy library of the Hong Kong Lutheran Social Service, which tapped cognitive components (1) EF (problem-solving)
challenge highly similar to that included in the activity book of JCCPA (p. 50; 2008). Tokens representing different types and numbers of (2) Attention
dim-sum, instead of written words used in the activity book, were randomly placed on a board. Players took turn to play the (3) Memory
dice which indicated type and number of dim-sum to collect. Players had to collect the respective dim-sum tokens as fast as
possible. Player who collected the most tokens won.
Domino The activity was based on an activity suggested in the activity book of JCCPA (p. 88; 2008). PWA were asked to stack the dominos
(1) EF (reasoning, planning and
stacking together with different patterns (e.g., a big circle, a spiral). PWA took turn to topple one of the dominos and observe if all the
organization)
dominos fell. (2) Visual-motor processing
(3) Social cognition
Tabletop The activity was based on page 85 of the Jockey Club Center for Positive Ageing (2008), only differed by the use of stone pegs (1) Attention
curling instead of water bottles. Players were divided into two teams and each team was given four miniature stones. Players took (2) EF (problem solving Reasoning, plan
turn to glide the stones from the starting zone to the target house. The team with stone nearest to the target house won. ning and organization)
Players of the same team had to cooperate by pushing the stones of the opponents away from the target or by pushing the (3) Social cognition
stones of the partner closer to the target house.
APHASIOLOGY
11
allowing the covariate coefficient(s) of interest to vary randomly from one participant
to another, so that the response (or performance) trajectory of each subject over
time can be provided (Ma et al., 2012). It also allows cases with missing data points,
which is sometimes difficult to avoid in treatment studies where participants may
become unavailable for testing due to various reasons. With this advantage, the
cases can be retained and be ‘forced’ into statistical analyses. The statistical power is
thus better reserved.
Linear MEM modeling with restricted maximum likelihood estimation was conducted
using the gamlj package (Gallucci, 2019) installed and run on the statistical software
jamovi (The jamovi project, 2020). In investigating the effects of CS on nonverbal cogni
tive functions of the PWA, the two cognitive factors identified from the PCA were
regarded as the dependent variables; treatment condition (‘CT + CS’ vs. ‘CT’) and time
point (baseline/ mid-treatment/ post-treatment/ maintenance) were inputted as fixed
factors while the possible interaction among treatment condition and timepoint was also
considered in the model. As for the investigation of CS on language outcomes of the PWA,
a similar procedure was applied, with the three story probes as dependent variables and
treatment condition, timepoint, and fluency type (fluent vs. non-fluent) as fixed factors.
Meanwhile, their performance on sentence comprehension, which differed between the
two treatment conditions in baseline, was regarded as a co-variate. The interactions
among the fixed factors were investigated by initially implementing a more complex
model comprising fixed factors and their interactions, i.e., treatment condition
x timepoint x fluency type. If no significant interaction effect was observed, then
a simpler model with additive terms only would be adopted. To examine the possible
changes across the timepoints, the same procedures were applied on the language
control task and sentence comprehension task.
In terms of random effects structure modelling, only intercepts for subjects were
considered, as inclusion of other random effects was constrained by the limited number
of observations available and therefore became impossible. Once the optimal model had
been determined, outliers with residuals ±2.5 SDs from the mean were then eliminated
from the model and the data were then re-fitted. Outlier detection was done via IBM SPSS
Statistics 26, as the function of residual investigation was not available in gamlj package.
Any significant effects of the fixed factors would be further explored by post-hoc compar
isons with the p values adjusted by FDR correction.
Reliability and fidelity measures

About 10% of the data, including language samples and scoring forms of the cognitive
and linguistic tests, were randomly extracted and blindly scored by the author again and
by another speech therapist to examine intra-rater and inter-rater reliability. Point-to-
point reliability measurements were calculated, based on the formula - Total agreement/
(Total agreements + Total disagreement) X 100%.
Treatment fidelity of language treatment was carried out by inviting a speech therapist
who was not involved in treatment delivery as the assessor. Guidelines recommended by
the National Institutes of Health’s Behavior Change Consortium (Bellg et al., 2004) for
monitoring treatment delivery were adopted. Five sessions of language therapy were
randomly selected from each of the treatment conditions and from each of the language
APHASIOLOGY 13
Table 5. Checklist for Fidelity Testing on Treatment Delivery.

(1) Materials (e.g., comics/videos) were only shown to the PWA whereas the communication partner had no knowl
edge of them.
(2) Supplementary materials including pen and paper, pictures depicting main characters of Old Master Q, note for
suggestion on communication strategies for the dyad and story grammar element chart were available and
accessible by the dyad.
(3) Communication partner interacted with PWA, and used compensatory strategies (e.g., use of story grammar
elements, asking prompting questions, ask/repeat for clarifications)
(4) Clinicians provided support to facilitate use of communication strategies or intervene the interaction of the dyad if
misunderstanding occurred and could not be repaired by the dyad.
(5) Communication partner was asked to retell the content of the materials at the end of the communication
exchange. This process may repeat until all content was agreed upon by the PWA.
training phases for a fidelity check. A checklist indicating the procedures of treatment
delivery was compiled (see Table 5). The assessor went through the video/audio taped
sessions to evaluate if treatment was delivered as planned.
Results
Baseline performance of PWA in cognitive and linguistic tasks
The results of mixed ANOVAs evaluating baseline language and cognitive perfor
mances are shown in Table 6. Both groups performed better in cognitive factor 1
(simple attention and memory) in the second baseline point, while participants in the
‘CT + CS’ treatment condition performed better than the ‘CT’ group in the sentence
comprehension task. No significant differences between timepoints and treatment
conditions were found in all other measures. No interaction between timepoints and
conditions was identified. In view of the better performance in Factor 1 in the second
baseline assessment and the difference in sentence comprehension between the two
treatment groups, more stringent procedures were applied in subsequent data
analyses. First, the baseline performance of all tasks was referred to the scores
obtained in the second pre-treatment assessment. Second, raw scores of sentence
Table 6. Summary Table of Mixed ANOVAs on Baseline Performance of PWA Various Cognitive and
Linguistic Domains.
Time Condition Time*Condition
Linguistic tasks
CAB .22 (1, 41), p = .64 4.14 (1, 41), p = .05 2.10 (1, 41), p = .15
Sentence comprehension raw score 1.32 (1, 35), p = .26 9.80 (1, 35), p < .01* .10 (1, 35), p = .76
Language outcomes
Comic 1 3.37 (1, 42), p = .07 .63 (1, 42), p = .43 .37 (1, 42), p = .55
Comic 2 2.68 (1, 43), p = .11 .47 (1, 43), p = .50 5.12 (1, 43), p = 1.00
Idiom 4.12 (1, 44), p = 0.05 1.79 (1, 44), p = .19 .36 (1, 44), p = .55
Language control task
Eggham .01 (1, 43), p = .92 1.21 (1, 43), p = .30 1.98 (1. 43), p = .17
Cognitive components
Factor 1: Simple attention and memory 8.80 (1, 35), p = .01* 2.43 (1, 35), p = .13 1.36 (1, 35), p = .25
Factor 2: Executive functions .08 (1, 31), p = .78 .63 (1, 31), p = .43 .02 (1, 31), p = .89
Note. Degrees of freedom in parenthesis. CAB = Cantonese Aphasia Battery.
14
Table 7. Summary of Number of PWA Who Completed the Tasks, and Means and Standard Deviations of Participants’ Performance on Various Language and
Cognitive Measures Across Assessment Timepoints.
Pre-treatment
Assessment time-point (2nd baseline point) Mid-treatment Post-treatment Maintenance
Treatment condition CT + CS CT CT + CS CT CT + CS CT CT + CS CT
Language outcomes
W. W. WONG AND S. P. LAW
Comic 1c 35.07 28.99 40.58 30.83 42.59 32.36 40.94 34.94

(27.14) (28.99) (29.09) (29.30) (30.58) (25.91) (28.16) (29.56)
n = 24 n = 23 n = 23 n = 20 n = 24 n = 20 n = 23 n =19
Comic 2c 41.25 34.24 47.68 35.61 42.59 41.17 44.78 39.65
(29.37) (27.53) (30.79) (29.23) (30.64) (29.06) (32.24) (28.61)
n = 24 n = 22 n = 23 n = 19 n = 23 n = 20 n = 23 n = 19
Idiomc 28.55 18.86 32.61 17.78 33.72 22.12 35.02 25.56
(26.16) (21.03) (26.45) (20.10) (27.68) (23.10) (28.09) (25.71)
n = 24 n = 22 n = 23 n = 20 n = 24 n = 19 n = 22 n = 20
Control
Egghamb -1.98 (1.31) -2.19 (1.89) -1.76 (1.35) -1.90 (1.25) -1.85 (1.39) -1.76 (1.47) -1.70 (1.44) -1.83 (1.26)
n = 23 n = 23 n =22 n = 21 n = 20 n = 22 n = 23 n =19
Cognitive Outcomes
Factor 1b -5.22 (3.37) -8.59 (5.37) -5.28 (3.77) -7.10 (4.66) -4.22 (3.35) -7.24 (4.50) -5.41 (4.03) -6.54 (4.49)
n = 22 n = 20 n = 19 n = 19 n = 20 n = 20 n = 21 n = 13
Factor 2b -2.16 (1.60) -2.49 (1.66) -1.63 (1.79) -1.91 (1.74) -1.71 (2.07) -1.60 (1.78) -1.64 (2.02) -1.63 (1.60)
n = 18 n = 18 n = 19 n =16 n = 18 n = 16 n = 19 n = 12
Sentence comprehend-sion (as a covariate) 25.81 (3.56) 22.55 (3.83) 25.70 (2.94) 23.58 (3.98) 26.10 (3.68) 23.14 (4.45) 25.88 (4.00) 22.41 (5.11)
n = 21 n = 22 n = 20 n = 19 n = 20 n = 21 n = 16 n = 17
Note. CT + CS = Conversation therapy plus cognitive stimulation; CT = Conversation therapy; n = Number of participants completed the task; Factor 1 = Simple attention and memory; Factor 2 =
EF.
a
Normed z-scores. bAge-normed z-scores. cPercentage correct.
APHASIOLOGY 15
comprehension in the respective timepoints were inputted as a covariate in running

mixed effects models of language and cognitive outcome measures, so as to monitor
its potential influence on language outcomes.
Summary of mixed effects models

Table 7 provides a summary of the number of PWA who completed various assessments
and their performance on various language and cognitive measures by treatment condi
tions across different timepoints. It is noted that most of the PWA (> 80%) completed
language outcome measures across all timepoints. Whereas for cognitive outcomes,
about 75% and 78.3% of the participants completed the tasks reflecting Factor 2 (i.e.,
EF) in baseline assessment in the ‘CT + CS’ and ‘CT’ treatment conditions, respectively. In
the maintenance timepoint, the number of PWA in the ‘CT’ condition who completed
such tasks dropped to 12. Similarly, the number of participants in the ‘CT’ group who
completed tasks reflecting performance in Factor 1, i.e., simple attention and memory, in
the maintenance testing was 13, which was substantially lower than that in other time
points. The primary reason for the low completion rate was due to abortion by the
participants.
The dataset was subsequently analyzed with mixed effects models, which aimed to
examine if the participants benefited from treatment in linguistic and cognitive aspects,
and whether the two treatment conditions would induce different effects on these two
domains. The final models of mixed effects analyses are given in Table 8.
Treatment effects on language outcomes and control task

Table 9 illustrates the level of significance of F statistics of the fixed variables including
time, condition, fluency type, as well as performance on sentence comprehension. It
shows that the effects of time and fluency type were significant in all of the three story
probes, i.e., the language outcomes. No difference between the two treatment conditions
was observed across the three probes, and no interaction existed among time, condition,
and fluency type. PWA’s ability in sentence comprehension was a significant covariate of
Table 8. Final Models for Each Cognitive and Linguistic Outcome Measure Across Treatment Period of
the Two Training Conditions.
Measure Final model
Cognitive outcomes measures
Factor 1 Factor 1 ~ 1 + Time * Condition + (1 | Subject)
Factor 2 Factor 2 ~ 1 + Time * Condition + (1 | Subject)
Language outcome measures
Comic 1 Comic 1 ~ 1 + Time * Condition + Fluency type + Sentence + (1 | Subject)
Comic 2 Comic 2 ~ 1 + Time * Condition + Fluency type + Sentence + (1 | Subject)
Idiom Idiom ~ 1 + Time * Condition + + Fluency type + Sentence + (1 | Subject)
Control measure
Eggham Eggham ~ 1 + Time * Condition + Fluency type + (1 | Subject)
Sentence comprehension (as a co-variate) Sentcomp ~ 1 + Time * Condition + Fluency type + (1 | Subject)
Note. The first term in each model is the dependent variable, while terms following ~ are predictor variables. Predictor
variables separated by * were tested for both additive effects and interactive effects, whereas those separated by +
were examined for additive effects only. EggHam = Procedural description of preparing an egg and ham sandwich from
the Cantonese Aphasia Bank. Factor 1 = Simple attention and memory. Factor 2 = EF.
Table 9. Summary of Effects of Predictor Variables on

Language Performance.
Tasks F p
Language Tasks
Comic 1
Time 4.75 (3, 93.56) < .01
Condition .19 (1, 34.64) .67
Fluency type 89.86 (1, 44.43) < .001
Sentence 8.74 (1, 132.84) < .01
Time*Condition .18 (3, 93.54) .91
Comic 2
Time 7.39 (3, 95.39) < .001
Condition .10 (1, 37.43) .75
Fluency type 75.54 (1, 47.17) < .001
Sentence 4.18 (1, 137.92) .04
Time*Condition .29 (3, 95.37) .84
Idiom
Time 7.16 (3, 93.87) < .001
Condition 1.06 (1, 37.64) .31
Fluency type 58.89 (1, 45.96) < .001
Sentence 2.11 (1, 130.69) .15
Time*Condition .32 (3, 93.73) .81
Eggham
Time 2.33 (3, 103.48) .08
Condition .30 (1, 40.98) .59
Fluency Type 33.10 (1, 40.91) < .001
Time*Condition 1.19 (3, 120.55) .32
Sentence comprehension
Time .47 (3, 108.25) .70
Condition 5.01 (1, 41.49) <.03
Fluency Type 32.40 (1, 41.48) < .001
Time*Condition .48 (3, 108.24) .69
Note. Satterthwaite method for degrees of freedom. *Significant after
Benjamini-Hochberg adjustment. EggHam = Procedural description of
preparing an egg and ham sandwich from the Cantonese Aphasia Bank.
performance in narrating comic 1 and comic 2. The performance of sentence comprehen

sion task, and procedural description of making an egg and ham sandwich serving as
a language control task, did not change over time in either of the treatment conditions.
The test statistics of time, with baseline performance as reference and compared
against other timepoints, together with those of other fixed variables, are shown in
Table 10. Since PWA’s performance in the language outcome measures changed over
time, while no significant difference was found between the two treatment conditions,
participants’ performance of both groups at the respective timepoint was combined to
allow investigation across different timepoints via post-hoc pair-wise comparisons. The
results of t-test statistics with Bonferroni adjustment are shown in Table 11. For all three
language outcome measures, participants performed better in both post-treatment and
maintenance periods when compared to baseline, while their performance did not differ
between post-treatment and maintenance phases. Fluency type was a factor in predicting
PWA’s performance on all language tasks.
APHASIOLOGY 17
Table 10. Summary of Fixed Effects of Parameters on Language Performance.

Coefficient SE t p 95% CI
Language Measures
Comic 1
Time effect
Mid (Pre as reference) 4.71 2.15 2.19 .03 .49 – 8.92
Post (Pre as reference) 6.99 2.10 3.33 .001 2.87 – 11.11
Main (Pre as reference) 6.71 2.21 3.03 .003 2.38 – 11.05
Condition effect (Lang as reference) -1.68 3.87 - .43 .67 -9.26 – 5.90
Fluency effect (nonfluent as reference) 40.76 4.30 9.48 < .001 32.33 – 49.19
Sentence comprehension effect 1.24 .42 2.96 .004 .42 – 2.06
Comic 2
Time effect
Mid (Pre as reference) 4.35 2.08 2.09 .04 .27 – 8.43
Post (Pre as reference) 9.26 2.01 4.61 < .001 5.32 – 13.19
Main (Pre as reference) 5.90 2.11 2.79 .006 1.76 – 10.04
Condition effect (Lang as reference) 1.43 4.49 .32 .75 -7.38 – 10.24
Fluency effect (non-fluent as reference) 42.49 4.89 8.69 < .001 32.91 – 52.07
Sentence comprehension effect .87 .43 2.05 .04 .04 – 1.71
Idiom
Time effect
Mid (Pre as reference) 2.59 1.64 1.57 .12 -.63 – 5.80
Post (Pre as reference) 5.44 1.58 3.44 < .001 2.34 – 8.54
Main (Pre as reference) 6.97 1.68 4.14 < .001 3.67 – 10.28
Condition effect (Lang as reference) 4.54 4.41 1.03 .31 -4.11 – 13.19
Fluency effect (non-fluent as reference) 36.07 4.70 7.67 < .001 26.86 – 45.28
Sentence comprehension effect .52 .36 1.45 .15 -.18 – 1.21
Eggham (control task)
Time effect
Mid (Pre as reference) .26 .12 2.21 .03 .03 – .50
Post (Pre as reference) .25 .12 2.08 .04 .01 – .48
Main (Pre as reference) .25 .13 2.01 .05 .00 – .50
Condition effect (Lang as reference) - .16 .30 -.55 .59 -.75 – .42
Fluency effect (non-fluent as reference) 1.72 .30 5.75 < .001 1.13 – 2.30
Sentence comprehension (as a co-variate)
Time effect
Mid (Pre as reference) .36 .39 .90 .37 -.41 – 1.13
Post (Pre as reference) .13 .39 .32 .75 -.63 – .89
Main (Pre as reference) -.12 .42 -.28 .78 -.93 – .70
Condition effect (Lang as reference) 1.90 .85 2.24 .03 .24 – 3.57
Fluency effect (non-fluent as reference) 4.83 .85 5.69 < .001 3.17 – 6.50
Note. EggHam = Procedural description of preparing an egg and ham sandwich from the Cantonese Aphasia Bank. Pre =
Pre-treatment performance obtained from the second pre-test; Mid test; Post = Post-test; Main = Maintenance.
Treatment effects on cognitive performance

Table 12 summarizes the results of F tests showing the effects of time and condition
on the two cognitive factors. The effect of time was significant in both cognitive
factors while condition was not. No interaction between time and condition was
found. The effects of the two fixed factors with respect to their reference conditions
are illustrated in Table 13. As the effect of condition was not observed, post-hoc
comparisons of PWA’s performance across the four timepoints were calculated with
the two treatment conditions combined. According to Table 14, which shows the
results of t-test analyses with Bonferroni adjustment, the participants performed
Table 11. Post-hoc Comparisons of Time in Various Language Measures.

Comparison
Time Time Difference SE t df p (Bonferroni correction)
Comic 1 Pre Mid -4.59 2.15 -2.14 102.3 .21
Pre Post -7.06 2.10 3.36 101.9 .01
Pre Main -6.39 2.21 -2.89 102.0 .03
Mid Post -2.47 2.18 -1.13 101.6 1.00
Mid Main -1.80 2.33 -.78 102.5 1.00
Post Main .67 2.31 .29 102.4 1.00
Comic 2 Pre Mid -4.37 2.08 -2.10 101.6 .23
Pre Post -9.09 2.01 -4.52 100.8 < .001
Pre Main -5.83 2.12 -2.74 100.7 .04
Mid Post -4.73 2.09 -2.26 100.8 .16
Mid Main 1.46 2.23 -.66 101.5 1.00
Post Main 3.27 2.21 1.48 101.2 .85
Idiom Pre Mid -2.83 1.63 -1.74 100.2 .52
Pre Post -5.53 1.58 -3.51 99.59 .004
Pre Main -7.02 1.68 -4.17 99.64 < .001
Mid Post -2.71 1.64 -1.65 99.59 .61
Mid Main -4.19 1.77 -2.37 100.41 .12
Post Main -1.48 1.75 -.85 100.07 1.00
Eggham Pre Mid -.28 .11 -2.46 123.8 .09
Pre Post -.27 .11 -2.40 124.0 .11
Pre Main -.25 .11 -2.19 124.0 .18
Mid Post .00 .11 .03 123.4 1.00
Mid Main .03 .11 .23 123.4 1.00
Post Main .02 .12 .21 123.3 1.00
Sentence comprehension (as a covariate) Pre Mid -.36 .39 -.90 107.7 1.00
Pre Post -.13 .39 -.32 107.2 1.00
Pre Main .11 .42 .57 108.1 1.00
Mid Post .23 .40 .58 106.8 1.00
Mid Main .47 .42 1.11 107.7 1.00
Post Main .24 .42 .57 108.1 1.00
Note. EggHam = Procedural description of preparing an egg and ham sandwich from the Cantonese Aphasia Bank. Pre =
Pre-treatment performance obtained from the second pre-test; Mid = Mid test; Post = Post-test; Main = Maintenance.
Table 12. Summary of Effects of Predictor Variables on Cognitive Outcomes.

Tasks F p
Factor 1 (simple attention and memory)
Time 3.23 (3, 87. 86) .03
Condition 3.87 (1, 40.85) .06
Time*Condition 1.16 (3, 87.86) .33
Factor 2 (EF)
Time 7.20 (3, 103.70) < .001
Condition .03 (1, 42.84) .86
Time*Condition 1.10 (3, 103.70) .35
Note. Satterthwaite method for degrees of freedom. *Significant after Benjamini-Hochberg adjustment.
better in post-treatment when compared to baseline in cognitive Factor 1 of simple

attention and memory. However, performance in maintenance phase was no longer
different from that in the baseline assessment. In contrast, PWA performed better
than baseline in both post-treatment and maintenance phases for cognitive Factor 2
representing EF, while their performance in post-treatment and maintenance stages
was similar.
APHASIOLOGY 19
Table 13. Summary of Fixed Effects of Parameters on Cognitive Outcomes.

Coefficient SE t p 95% CI
a
Factor 1: Simple attention and memory
Time effect
Mid (Pre as reference) .48 .31 1.52 .13 -.13 – 1.09
Post (Pre as reference) .92 .32 2.91 .01 .30 – 1.54
Main (Pre as reference) .74 .33 2.20 .03 .08 – 1.39
Condition effect (Lang as reference) 2.51 1.27 1.98 .05 .02 – 4.99
Factor 2: EFb
Time effect
Mid (Pre as reference) .41 .17 2.44 .02 .08 – .73
Post (Pre as reference) .68 .17 4.07 < .001 .35 – 1.00
Main (Pre as reference) .64 .17 3.64 < .001 .29 – .98
Condition effect (Lang as reference) .10 .51 .20 .84 -.89 – 1.10
Note. Pre = Pre-treatment performance obtained from the second pre-test; Mid test; Post = Post-test; Main =
Maintenance.
a
Two outliers were identified and eliminated from subsequent analyses. bOne outlier was identified and eliminated from
subsequent analyses.
Table 14. Post-hoc Comparisons of Time in the Two Cognitive Domains.

Comparison
Time Time Difference SE t df p (Bonferroni correction)
Factor 1 Pre Mid -.48 .31 -1.52 90.95 .79
Pre Post -.92 .32 -2.91 91.10 .03
Pre Main -.74 .33 -2.20 91.68 .18
Mid Post -.44 .31 -1.41 90.60 .98
Mid Main -.26 .33 -.80 90.87 1.00
Post Main .18 .33 .55 91.12 1.00
Factor 2 Pre Mid -.41 .17 -2.44 106.4 .10
Pre Post -.68 .17 -4.07 106.9 < .001
Pre Main -.64 .17 -3.64 106.8 .003
Mid Post -.27 .17 -1.57 107.3 .72
Mid Main -.23 .18 -1.27 106.9 1.00
Post Main .04 .18 .23 107.1 1.00
Note. Factor 1 = Simple attention and memory; Factor 2 = EF; Pre = Pre-treatment performance obtained from the second
pre-test; Mid = Mid test; Post = Post-test; Main = Maintenance.
Reliability and fidelity measures

Point-to-point intra-rater and inter-rater reliability were 98.33% and 93.33%, respectively.
Fidelity checks based on the checklist provided in Table 5 were conducted by a speech
therapist with more than five years of clinical experience in the rehabilitation of neuro
genic communication disorders. They revealed that treatment procedures conformed to
the checklist 96% of the time.
Discussion
The current preliminary study aimed to investigate whether non-linguistic CS would
enhance the cognitive performance of PWA, and whether such improvements might in
turn benefit language outcomes of PWA receiving conversation therapy. Contrary to
prediction, both treatment groups of PWA, irrespective of the presence of CS, showed
comparable improvements in both cognitive and linguistic outcomes. Furthermore,

treatment effects on EF and language outcomes were maintained at least 8-week post-
treatment.
The significant improvements in language outcome measures, regardless of CS, can be
attributed to conversation therapy being effective in promoting functional communica
tion of PWA (Hopper et al., 1999, 2002). The positive changes were not likely due to
practice effects, since PWA’s performance on the control language task and sentence
comprehension scores did not change upon repeated evaluation. Without the support
from the clinicians and upon a more stringent scoring criterion, i.e., credits were only
given to productions initiated by the PWA without explicit cueing or prompting by the
communication partners, the PWA were still able to produce more accurate concepts
depicting the comics/short video probes measured immediately after treatment and
8-week post-treatment, respectively. Furthermore, both fluent/non-fluent PWA seemed
to benefit from the treatment protocol. Nevertheless, such an improvement is specific to
selective context and macro structure, as no change was observed in the control language
task.
The impact of conversation therapy on cognitive functioning of PWA: a possible

account and direction for future studies
While improvement in language performance attributable to conversation therapy is
expected, the unexpected findings of the cognitive gains may provide important insights
into the nature of rehabilitation of aphasia. The concurrent improvements in functional
communication and cognitive functions might be best explained by the concept of neural
multifunctionality that language performance results from the ‘constant and dynamic
interaction among linguistic and non-linguistic neural systems’ (Cahana-Amitay, 2015;
p. 3)’. In other words, the gains in cognitive outcome could be associated with an
improved dynamics between the linguistic and non-linguistic cognitive domains.
Following the hypothesized mechanism just described, the improvements in cognitive
functions, EF in particular, could be achieved via explicit metacognitive training
embedded in a functional and interactive context during conversation therapy.
Specifically, when a comic strip is presented to PWA, EF could be expected to be recruited
in idea formation and organization as suggested in Baker et al. (2020); cognitive flexibility
would be required when PWA attempt to overcome difficulties in communication by
selecting appropriate compensatory strategies (Frankel et al., 2007; Beckley et al., 2013).
Monitoring of communication success upon feedback from clinicians and communication
partner, and making adjustments in verbal output or change in compensatory strategies
to fix communication breakdown would also involve EF, including planning, information
update and problem solving. In other words, PWA were required to multi-task while these
skills were practised and mastered upon explicit instruction and feedback given by the
clinician. It is argued that the language treatment protocol adopted in this study may
have actively recruited EF abilities and promoted functional communication simulta
neously, resulting in gains observed in both language and EF.
It is noteworthy that the positive finding in EF was somewhat inconsistent with Spitzer
et al. (2021), in which the authors proposed several reasons to account for absence of
improvement in nonverbal EF task. One of them concerned the nature of the treatment
APHASIOLOGY 21
protocol being merely beneficial to verbal cognitive flexibility but unable to generalize to
tasks recruiting nonverbal EF. The discrepancy between the current study and Spitzer
et al. (2021) might be due to the differences in the tasks measuring EF (a group of tasks
reflecting EF extracted by PCA vs. the use of WCST alone). Another plausible difference
might lie in the treatment protocols used. In the current study, the PWA were required to
attend to both the communication partner and the clinician, while only PWA and
clinicians were present during metacognitive language therapy in Spitzer et al. (2021).
The demand for EF in engaging in a multi-party context is assumed to be greater, which
may account for the significant gain in EF.
In the meantime, the differential outcomes of the two cognitive factors in the main
tenance phase might be explained by their inherent differences during training. The
explicit and goal-directed training of conversation strategies might render internalization
and continual practice of such strategies possible in daily conversation of PWA in the
maintenance period. On the other hand, improvement in the attentional components and
STM/WM immediate post-treatment was attributed to intervention, albeit somewhat less
explicitly. For example, sustained attention was involved when PWA attended to the
visual/audio stimuli of the training materials. Selective attention was also required when
questions asking for clarification or specific information were made by the partners, such
that the PWA have to search for relevant information shown in the comics. STM/WM were
essentially involved during information processing and manipulation. However, the
implicit nature of intervention in attention and memory in the treatment process might
render PWA less readily or effectively in utilizing the relevant skills in daily conversations.
Hence, the gains in such abilities were no longer detected during maintenance assess
ment. Nonetheless, it is worth noting that the absence of maintenance of simple attention
and memory did not seem to diminish the retention of language performance.
The present study, albeit preliminary, calls for further exploration of the crucial
factors and principles of aphasia therapy contributing to treatment success. The con
cept of impairment-based vs. functional approaches to aphasia treatment, based on the
International Classification of Functioning, Disability and Health (ICF; World Health
Organization, 2019), has been regarded the most influential framework in clinical
aphasiology. However, neither approach have given adequate consideration to the
dynamics and impact brought about by other cognitive domains. Indeed, if one refers
to the classification system of cognitive intervention, which is neither widely discussed
nor investigated in aphasia research, the current protocol of conversation therapy fits
into the concept of cognitive rehabilitation because (1) it is a functional activity, (2)
individual treatment goals are defined to facilitate communication for each of the dyad,
(3) training involves strategies to compensate for the deficit in communication, and (4)
partners (for communication) play a role in the process. In addition, how the concept of
cognitive rehabilitation may be adopted in aphasia therapy targeting different language
modalities/levels should receive more attention. For instance, treatments that aim for
improving sentence comprehension should incorporate the strategies into a real-life
context, e.g., face-to-face conversation or phone chat with treatment goals clearly
explained to the PWA. The responses from the clinician/communication partner would
provide authentic feedback to the PWA, so as to help them cope with realistic commu
nication scenarios. Moreover, the roles of some elements in treatment success should
deserve further investigation, including explicit instruction/cueing and feedback to
increase participants’ awareness and self-monitoring of using specific strategies or self-

cues to achieve the goals (see Best et al., 2016 for the use of video feedback for
conversation behaviours), recruitment of metacognitive skills in achieving the goals,
as well as utilization of interactive and socially-engaging treatment environment as
suggested in Stahl et al. (2016).
Given the benefits to cognitive abilities of PWA as a possible ‘by-product’ of conversa
tion therapy, it is strongly suggested that the cognitive functions of the participants
should be monitored throughout intervention, which was not considered in many pre
vious studies. One can even go further to compare the effects of different language
intervention protocols on cognitive functioning of PWA. It is reasonable to hypothesize
that treatment utilizing metacognitive strategies, when compared to those repetition-
based approach with minimal involvement on EF/other cognitive components, may have
greater impact on one’s cognitive processing.
Last but not least, the relatively low and comparable attrition rates of the two treat
ment protocols (one PWA in the ‘CT + CS’ group and two PWA in the ‘CT’ group) suggest
that both are clinically viable. The applicability and efficacies of such treatment protocols
in other clinical populations with co-morbid cognitive impairment and neurogenic com
munication disorders, e.g., people with primary progressive aphasia or right hemispheric
syndrome, are worthy of investigation.
The lack of improvements in cognitive measures of PWA after cognitive

stimulation: some possible accounts and suggestions for future exploration
In this initial attempt to investigate the effects of CS on PWA, albeit a multitude of reports
of beneficial effects of CS on people with dementia (PWD), positive change was not seen.
Some plausible reasons are proposed to account for the absence of benefits of CS on
PWA. Firstly, major differences exist in the neuropathology of dementia and stroke
(Sopova et al., 2014), their differential receptiveness towards various approaches of
cognitive intervention may not be unexpected. By contrasting the findings from the
current study regarding the benefits of conversation therapy to both cognitive and
language functioning with the lack of treatment effect of CS, we tentatively suggest
that implicit and stimulation-based intervention or the dosage of exposure provided in
this study might be insufficient for enhancing PWA’s cognitive functioning.
Another possible explanation may be related to the use of non-linguistic stimuli in the
CS activities of the current study, which is critically different from the conventional CST in
the dementia population where spoken and written stimuli are used throughout the
intervention program. In fact, the benefits on functional communication of PWD brought
about by CST (Spector & Woods, 2010), as reflected in Holden Communication Scale and
language sub-scale of the Alzheimer’s Disease Assessment Scale – Cognitive Subscale
(ADAS-Cog), could arguably be attributed to the intensive use of language during inter
vention. In other words, if the cognitive activities in the present investigation had adopted
more language content instead of non-linguistic stimuli, the gains in cognitive functions
among PWA might have more readily transferred to performance on the language tasks.
APHASIOLOGY 23
Limitations
The present study employed mixed effects models to evaluate treatment effects on PWA.
Despite its tolerance of randomly missing data, it should be noted that fewer participants
had completed the cognitive tasks in the maintenance timepoint; hence, the results
associated with the cognitive performance during maintenance should be treated with
caution. Another limitation concerned the use of mixed effects model in the current study
that only random slopes of the predicted variables of the participants were entered in the
model to estimate the random effects. To avoid overfitting of model, random effects of
participants in predictors like timepoint were not included. If more assessments were taken
throughout the course of treatment by adding a third assessment in pre-treatment and
another between mid-treatment and post-treatment, its random effects could be estimated.
Due to limited resources and manpower, some aspects of the overall study design were
compromised, arguably jeopardizing the quality of evidence. First, fidelity check for the
implementation of non-linguistic CS would have been done properly if a certified CST
trainer unrelated to the study was invited. Second, when the level of treatment evidence
was systematically evaluated by the Critical Appraisal of Treatment Evidence (CATE;
Dollaghan, 2007), two out of the 15 appraisal points were not fulfilled. They included
Point Four (random assignment of participants) and Point Nine (blinding of the assessors,
clinicians and participants in outcome evaluation).
Contrary to the current design with two treatment groups (i.e., ‘CT + CS’ vs. ‘CT’),
a factorial design with inclusion of two more groups, namely ‘CS’ only and ‘No treatment’,
would better delineate the possible effects of CS and conversation therapy on the
participants’ performance. The concern over practice effects due to repeated testing
could be more properly handled by having a ‘No treatment’ group with the same
assessment schedule as others. The effects of cognitive stimulation, and the potential
effects arising from the difference in session length of the ‘CT + CS’ and ‘CT’ conditions,
could be more properly revealed by examining the cognitive and language outcomes of
the 1-hour ‘CS’ only group delivered with the same intensity as in other treatment
conditions.
Finally, some of the factors that are believed to play a role in the outcome of CST in
dementia populations, namely socio-economic status and in particular cognitive reserve
(Kalbe & Folkerts, 2018), were not documented in the participants of this study. Future
studies overcoming the above-mentioned limitations will continue to contribute to topics
in aphasiology and its rehabilitation.
Conclusions
The preliminary findings of the present investigation provide important insights into
the rehabilitation of PWA. Given the benefits of the current language treatment
protocol to the cognitive performance (especially EF) and functional communication
of PWA, the components contributing to treatment success, including a naturalistic
and interactive training context, explicit/goal-directed practice of strategies, and
involvement of multi-cognitive skills, should be incorporated in future intervention
studies. Despite of the absence of evidence for improvement in performance of
cognitive functions and functional communication attributable to the CS protocol,
it seems premature to rule out the potential effect of CS on PWA or patients with
neurogenic communication disorders. On the contrary, it may be the beginning of
a fruitful line of research.
Note
1 The online repository can be accessed via https://dataverse.harvard.edu/dataset.xhtml?
persistentId=doi:10.7910/DVN/DX9E00
Acknowledgments
We wish to express sincere gratitude to the Aberdeen Kaifong Association, Haven of Hope Christian
Service, Neighbourhood Advice-Action Council, Hong Kong Society for Rehabilitation, & SAHK for
participant recruitment and venue for data collection. We also thank the PWA and speech therapy
students as research interns from the University of Hong Kong for data collection. Credit is also
given to the financial support provided by the Seed Grant for Basic Research (grant code:
104004421.014304.10000.301.01).
Disclosure statement
The authors report there are no competing interests to declare. The authors report no conflict of
interest.
Funding
This work was supported by the University of Hong Kong [Seed Grant for Basic Research/ Grant
code: 04004421].
ORCID
Winsy Wing-Sze Wong http://orcid.org/0000-0003-0420-2964
Sam Po Law http://orcid.org/0000-0001-9337-3866
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Can non-linguistic cognitive stimulation enhance

Winsy Wing-Sze Wong & Sam Po Law

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Can non-linguistic cognitive stimulation enhance the

Conclusions: Based on the preliminary findings, improvements in

Proposal of the current study and methodological considerations

Materials and method

Figure 1. Timeframe of assessment and Treatment.

majority of the PWA (48 out of 53) were monolingual Cantonese-speakers. No

Table 1. Characteristics of PWA Who Completed Treatment Study.

Language assessment and outcomes

Cognitive assessment and outcomes

Table 2. Principal Component Loadings from

Reliability and fidelity measures

Table 5. Checklist for Fidelity Testing on Treatment Delivery.

Comic 1c 35.07 28.99 40.58 30.83 42.59 32.36 40.94 34.94

comprehension in the respective timepoints were inputted as a covariate in running

Summary of mixed effects models

Treatment effects on language outcomes and control task

Table 9. Summary of Effects of Predictor Variables on

performance in narrating comic 1 and comic 2. The performance of sentence comprehen­

Table 10. Summary of Fixed Effects of Parameters on Language Performance.

Treatment effects on cognitive performance

Table 11. Post-hoc Comparisons of Time in Various Language Measures.

Table 12. Summary of Effects of Predictor Variables on Cognitive Outcomes.

better in post-treatment when compared to baseline in cognitive Factor 1 of simple

Table 13. Summary of Fixed Effects of Parameters on Cognitive Outcomes.

Table 14. Post-hoc Comparisons of Time in the Two Cognitive Domains.

Reliability and fidelity measures

comparable improvements in both cognitive and linguistic outcomes. Furthermore,

The impact of conversation therapy on cognitive functioning of PWA: a possible

increase participants’ awareness and self-monitoring of using specific strategies or self-

The lack of improvements in cognitive measures of PWA after cognitive

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