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Inner Speech in Post-Stroke Aphasia: a Behavioural and Imaging Study

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Inner Speech in Post-Stroke Aphasia: a Behavioural and Imaging Study Inner Speech in Post-Stroke Aphasia: A Behavioural and Imaging Study Sharon Geva Wolfson College Department of Clinical Neurosciences This dissertation is submitted for the degree of Doctor of Philosophy Declaration The text in this dissertation does not contain more than 60,000 words, excluding figures, tables, appendices and bibliography. This dissertation was not submitted for a degree or diploma or other qualification at any other university. This dissertation is the result of my own work and includes nothing which is the outcome of work done by others or in collaboration except where specifically indicated in the text. Summary Patients with aphasia often complain that there is a poor correlation between the words they think (inner speech) and the words they say (overt speech). Previous studies show that there are some cases in which inner speech is preserved while overt speech is impaired, and vice versa. However, these studies have various methodological and theoretical drawbacks. In cognitive models of language processing, inner speech is described as either dependent on both speech production and speech comprehension, or on the speech production system alone. Lastly, imaging studies show that inner speech is correlated with activation in various language areas. However, these studies are sparse and many have methodological caveats. Moreover, studies looking at inner speech in stroke patients are rare. This study examined inner speech in post-stroke aphasia using three different methodological approaches. Using cognitive behavioural methods, inner speech was characterised in healthy participants and stroke patients with aphasia. Using imaging, the brain structures which support inner speech were investigated. Two different methods were employed in this instance: Voxel based Lesion Symptom Mapping (VLSM) and Voxel Based Morphometry (VBM). Lastly, functional magnetic resonance imaging (fMRI) was used to study the dynamics of functional activations supporting inner speech production. The study showed that inner speech can remain intact while there is a marked deficit in overt speech. Structural studies suggested an involvement of the dorsal language route in inner speech processing, together with systems supporting motor feedback and executive functions. Functional imaging showed that inner speech processing in stroke is correlated with compensatory peri-lesional and contra-lesional activations. Activations outside the language network might reflect increase in effort or attention, or the use of feed forward and feedback mechanisms to support inner speech production. These results have implications for diagnosis, prognosis and therapy of certain patients with post-stroke aphasia. Acknowledgements Many people helped me throughout these years, and I cannot thank them all enough. I would like to mention the ones who were most directly involved with my work. Firstly, my supervisor, Liz Warburton, for her encouragement, enthusiasm and enormous professional and personal support, for giving me her love for knowledge, and for spending many hours discussing the mysteries of the human brain. I would also like to thank Jean-Claude Baron, for his help and advice throughout these years, and the members of the Stroke Research Group. I would like to thank the patients and their families for their time and efforts. My sincere thanks also go to Karalyn Patterson, who helped me enormously to understand the behavioural data, and Cathy Price and Jenny Crinion for their help with the imaging work. I would also like to thank: Simon Jones and Tulasi Marrapu, for many hours of analysis, statistics and programming and Diana Day for recruitment of patients. The WBIC radiographers, especially Jon Campbell, Tracy Mattick, Sean Kearns, Rosna Hoque, Vicky Lupson and the rest of the WBIC staff. Nicola Lambert, Helen Walker, Helen Palmer and Katherine Scantlebury for help with recruitment and testing of patients and for many hours of training they gave me, Sinead Stringwell for her help in the preparation of materials, and Sophie Bennet, for the help with the behavioural work. The Pinsent-Darwin Fellowship, Wingate scholarship, The Cambridge Overseas Trust and B’nai Brith Scholarship for their generous funding. And lastly, a big thanks to my parents, who always put our education on the top of their priorities. My parents started reading my home work the day I started learning the aleph-bet, and have not stopped since then. And my husband, Harith, who read my work, listened to my ideas and was supportive throughout the many up and down moments, and above all, always managed to give me this interesting outlook on my results, which only a medieval historian can. Table of Contents Chapter 1: Introduction 1 Part I: Stroke, Aphasia and its Therapy 1 1. Etiology of Aphasia 2 1.1 Historical Background 2 1.2 Functional Anatomy of Language 5 1.2.1 Functional Anatomy of Speech Comprehension 5 1.2.2 Functional Anatomy of Speech Production 7 1.2.3 Functional Anatomy of Reading 8 1.2.4 Functional Anatomy of Writing 9 2. Diagnosis of Aphasia 11 2.1 Diagnostic Tests 11 2.2 Main Problems with Current Diagnostic Tests 12 3. Recovery from Aphasia 13 3.1 Spontaneous Recovery after Stroke 13 3.2 Aphasia Rehabilitation 15 3.2.1 Aphasia Therapy 15 3.2.2 Neural Correlates of Aphasia Therapy 18 3.2.2.1 Case Studies of Therapies for Single Word Production 19 3.2.2.2 Therapy for Syntactic Processing 22 3.2.2.3 Group Studies 22 3.2.2.4 Summary 26 4. Theoretical Background of the Current Research 27 Part II: Inner Speech: Past Research and Current Models 29 1. Historical Perspectives 29 2. Current Models of Inner Speech 31 3. The Current Research 35 Chapter 2: Inner Speech in Normal Language Processing 38 1. Introduction 38 2. Methods and Materials 39 2.1 Participants 39 2.2 Materials 39 2.2.1 Rhyme and Homophone Judgement - Lists 1 and 2 39 2.2.2. Non-Word Homophone Judgement - List 3 40 2.2.3 Lexical Stress 40 2.3 Procedure 41 2.3.1 Rhyme and Homophone Judgements 41 2.3.2 Lexical Stress 41 3. Results 41 3.1 Rhyme and Homophone Judgement – Lists 1 and 2 41 3.2 Non-Word Homophone Judgement – List 3 46 3.3 Lexical Stress 48 4. Discussion 50 4.1 Standardisation of Tests 50 4.2 Relation between Inner and Overt Speech 52 4.3 Differences between Words and Non-Words 52 4.4 Lexical Stress 53 4.5 Conclusions and Future Directions 56 Chapter 3: Behavioural Investigation of Inner Speech in Aphasia 57 1. Introduction 57 2. Methods and Materials 62 2.1 Participants 62 2.1.1 Patients with Aphasia 62 2.1.2 Healthy Controls 63 2.2 Materials 65 2.3 Procedure 66 3. Results 67 3.1 Do stroke patients with aphasia have impairments of inner speech? 70 3.2 Do patients have dissociation between inner and over speech abilities? 74 3.3 Differences between Words and Non-Words 78 3.4 Case Studies 79 3.5 Do patients rely on inner speech or overt speech when the two differ? 81 4. Discussion 82 4.1 Inner Speech Abilities in Aphasia 83 4.2 Relation between Inner and Overt Speech 84 4.3 Differences between Words and Non-Words 89 4.4 Clinical Implications 91 4.5 Conclusions and Future Directions 92 Chapter 4: A Voxel-Based-Lesion-Symptom Mapping Study of Inner 94 Speech 1. Introduction 94 1.1 Lesion Analysis Techniques 94 1.2 Methodological Aspects of VLSM 96 1.3 Neural Correlates of Inner Speech 97 1.3.1 Studies of Inner Speech 97 1.3.2 Studies of Inner and Overt Speech 99 2. Methods and Materials 102 2.1 Participants 102 2.2 Procedure 102 2.2.1 Behavioural Testing 102 2.2.2 Imaging Data Acquisition 103 2.2.3 Data Analysis 103 3. Results 104 3.1 Neural Correlates of Language Production and Language 105 Comprehension 3.2 Neural Correlates of Inner Speech 106 4. Discussion 110 4.1 Lesion Analysis of Language Production and Comprehension 110 4.2 Neural Correlates of Inner Speech 111 4.3 Study Caveats 116 4.4 Conclusions and Further Research 117 Chapter 5: Voxel Based Morphometry Study of Inner Speech 118 1. Introduction 118 1.1 The Voxel Based Morphometry Technique 118 1.2 VBM Studies of Language 119 1.2.1 Studies of the Healthy Population 119 1.2.2 Studies of Stroke Patients 120 1.3 Age Related Structural Changes in the Brain 120 1.4 The Current Research 122 2. Methods and Materials 122 2.1 Participants 122 2.2 Materials 123 2.3 Procedure 123 2.4 Data Analysis 124 2.4.1 Images Preprocessing 124 2.4.2 Statistical Analysis 124 3. Results 126 3.1 Neural Correlates of Language Production and Comprehension 126 3.2 Neural Correlates of Inner Speech 127 3.3 The Effects of Ageing on Global and Language Related, Structural 135 Changes 3.4 Effects of Scanner Type 136 4. Discussion 136 4.1 Neural Correlates of Language Production and Comprehension 136 4.2 Neural Correlates of Inner Speech 137 4.2.1 The Perisylvian System’s Role in Inner Speech 138 4.2.2 The Inner Speech Executive System 139 4.2.3 The Motor System in Inner Speech 141 4.2.4 The Influence of Working Memory on Inner Speech 145 4.3 Methodological Aspects of the Current Study 146 4.4 Conclusions and Further Research 149 Chapter 6: An fMRI Investigation of Inner Speech 151 1. Introduction 151 1.1 Inner Speech in Functional Imaging Studies of Aphasia 151 1.2 Age Related Changes in Brain Activation of the Language System 153 1.3 Current Research 155 2. Methods and Materials 157 2.1 Participants 157 2.2 Materials 157 2.3 Procedure 159 2.4 Data Acquisition 161 2.5 Carotid Assessment 161 2.6 Data Analysis 161 2.6.1 Behavioural Data Analysis 161 2.6.2 fMRI Data Pre-processing and Analysis 162 3.
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