Research Report Brief mindfulness meditation group training in aphasia: exploring attention, language and psychophysiological outcomes

INT J LANG COMMUN DISORD, JANUARY FEBRUARY 2018, VOL. 53, NO. 1, 40 54 Research Report Brief mindfulness meditation group training in aphasia: exploring attention, language and psychophysiological outcomes Rebecca Shisler Marshall, Jacqueline Laures-Gore and Kim Love Communication Sciences and Special Education, University of Georgia, Athens, GA, USA Biomedical Health Sciences Institute, University of Georgia, Athens, GA, USA Communication Sciences & Disorders Program and Neuroscience Institute, Georgia State University, Athens, GA, USA Statistical Consulting Center, University of Georgia, Athens, GA, USA K. R. Love Quantitative Consulting and Collaboration, Athens, Georgia, USA (Received July 2016; accepted April 2017) Abstract Background: Stroke is currently the leading cause of long-term disability in adults in the United States. There is a need for accessible, low-cost treatments of stroke-related disabilities such as aphasia. Aims: To explore an intervention for aphasia utilizing mindfulness meditation (MM). This preliminary study examines the feasibility of teaching MM to individuals with aphasia. Since physiological measures have not been collected for those with aphasia, the study was also an exploration of the potential attention, language and physiological changes after MM in adults with aphasia during a brief, daily group training. Methods & Procedures: A 5-day MM group training was provided to adults with aphasia (n = 5) with a waitlist control group (n = (3) who engaged in mind wandering. Participants were assigned to groups in a pseudo-random manner. A double baseline (2 days apart) was administered prior to the training and/or control group beginning. Both the training and the control groups met in a group setting. Salivary cortisol, heart rate and heart rate variability were measured during each day for both groups. Measures of attention, auditory comprehension and fluency were collected immediately after the study period and 1 week post-completion. Outcome & Results: This study reinforces findings from previous work indicating that adults with aphasia can learn MM. Although not statistically significant, the training group demonstrated improved fluency immediately after MM; however, changes were not maintained at follow-up. Physiological measures showed little effect associated with MM training. No changes in attention were observed for either group. Conclusion & Implications: This is an emerging area of interest due to the potential low cost of MM training. Furthermore, MM is easily taught to patients, suggesting the possibility for widespread use in clinical practice as a supplement to existing language-focused interventions. Keywords: aphasia, mindfulness meditation, attention, fluency, heart rate variability, cortisol. What this paper adds What is already known on the subject A growing body of research has shown that MM may improve attention in neurologically intact individuals. Further evidence suggests that attention and language skills are closely linked, and both are impaired in aphasia. What this paper adds to existing knowledge Individuals with aphasia were able to complete mindfulness meditation, and changes in fluency were noted as well as a decrease in stress as measured by salivary cortisol. Address correspondence to: Rebecca Shisler Marshall, CCC-SLP, 534 Aderhold Hall, University of Georgia, Athens, GA 30606, USA; e-mail: rshisler@uga.edu International Journal of Language & Communication Disorders ISSN 1368-2822 print/issn 1460-6984 online C 2017 Royal College of Speech and Language Therapists DOI: 10.1111/1460-6984.12325

Mindfulness and aphasia 41 What are the potential or actual clinical implications of this work? This is an emerging area of interest because MM training is easily taught to patients and has potential for widespread use in clinical practice as a supplement to existing language-focused interventions. Introduction According to the Centers for Disease Control (CDC), stroke is the leading cause of long-term disability in adults in the United States with nearly 10% of adults over the age of 65 years surviving a stroke. The total cost of stroke-related expenditures from 2005 to 2050 is projected to be US$1.52 trillion for non- Hispanic whites, US$313 billion for Hispanics and US$379 billion for African-Americans (Wang et al. 2014). These figures underscore the need for accessible, low-cost treatments of stroke-related disabilities. To address this need, the current study examines clinically relevant outcomes of a potentially low-cost intervention for aphasia, a stroke-related disability, based on mindfulness meditation (MM). MM is a technique that improves self-regulation and cognitive control by fostering different types of attention (Cahn and Polich 2006, Rutschman 2004, Valentine and Sweet 1999). During MM, an individual directs the focus of attention to the breath. As focus begins to move to other thoughts or feelings, the individual is instructed to notice the shift in focus and redirect the focus back to the breath (Teasdale et al. 1995). Over time, mindfulness is thought to increase the range of attentional focus (Kabat-Zinn 1982). The effects of MM on cognitive performance, including attention regulation, are well documented in neurologically typical adults (e.g., Valentine and Sweet 1999, Wenk-Sormaz 2005). Several studies have demonstrated increased attention following MM. For example, Valentine and Sweet (1999) compared the performance of 19 mediators (including both concentrative and mindfulness techniques) and 24 controls on a sustained attention task. Both groups of mediators performed more accurately than the controls on the sustained attention task, indicating that meditation may have improved attention. Rutschman (2004) compared the performance of two groups with differing MM experience (novice, practised with MM) on a divided attention task. Performances of the two groups indicated that both meditation and relaxation improved attention capacity. However, the mediators performance increased significantly in comparison with the non-mediators. Rutschman further found that MM improved participants abilities to shift attention rapidly between two tasks, as well as increase readiness. Further, Jha et al. (2007) found effects of mindfulness-based stress reduction (MBSR) as measured by three aspects of attention: alerting, orienting and conflict monitoring. Alerting has been described as the basic wakefulness or arousal level, orienting involves selecting particular information, while conflict resolution consists of evaluating and resolving potential thought, feeling, and response differences (Rueda et al. 2005). Three groups of participants (no previous meditation experience control group, no previous meditation experience 8-week MBSR course, and previous experience in concentrative meditation 1-month retreat) were measured pre- and post-training using the Attention Network Test (ANT; Fan et al. 2002). No significant difference between alerting and orienting types of attention between the control group and experimental groups was observed at baseline; however, a significantly higher conflict monitoring performance was observed for the experienced mediators. This confirmed the authors hypothesis that prior experience with meditation may have long-term benefits for attention (Jha et al. 2007). At the conclusion of the training, the MBSR group increased performance on conflict monitoring, while the retreat group increased alerting performance. In other words, increasing practice increases the attention performance and potentially different subtypes of attention. Other studies have also demonstrated changes in the conflict monitoring subsystem of attention (Tang et al. 2007, Chan and Woollacott 2007, Moore and Malinowski 2009, Wenk-Sormaz 2005). For example, MM has been shown to correlate with higher attentional performance (Moore and Malinowski 2009) and may lead to improved selective attention as measured by the Stroop task (Wenk-Sormaz 2005). Additionally, changes in the orienting subsystem have been observed following MM training (MacCoon et al. 2014, MacLean et al. 2010). Finally, changes in attentional blink following MM have also been observed (Slagter et al. 2007, Van Leeuwen et al. 2009, Van den Hurk et al. 2010; for a review, see also Tang et al. 2015). Furthermore, there is a growing body of evidence for neurophysiological changes during MM that are consistent with modulation of attentional control (Cahn and Polich 2006, Lazar et al. 2000, Manna et al. 2010, Zeidan et al. 2010). There is some evidence that even short-term instruction in MM may improve attention, cognition and emotion (Zeidan et al. 2010, Tang et al. 2007). Tang et al. (2007) demonstrated improvements in attention and reductions in anxiety, depression, anger, fatigue and stress after 5 days of 20-min integrative

42 Rebecca Shisler Marshall et al. body mind training (IBMT). Similarly, Zeidan et al. (2010) found changes on tasks that require sustained attention executive processing with only 4 days of 20-min MM training. While MM appears promising as an intervention for attention, there is limited evidence regarding the use of MM in the treatment of aphasia (Kabat-Zinn 1982, Lazar et al. 2000). There is evidence that attention and language skills are closely linked, and both are impaired in aphasia (Murray 1999). Some earlier studies have shown some encouraging results using relaxation or MM in persons with aphasia (PWA; Marshall and Laures-Gore 2008, Marshall and Watts 1976, Laures-Gore and Marshall 2016, Murray and Ray 2001, Orenstein et al. 2012). However, missing in these studies are psychobiological assessment (cortisol, heart rate (HR) and heart rate variability (HRV)), which would offer potentially objective measures of the nervous system. Theoretically, aphasia may be highly amenable to MM training given that adults with aphasia present with attentional deficits (Murray 1999, 2000, Murray et al. 1997a, 1997b, 1998, Shisler 2005, Tseng et al. 1993). It is thought that these reductions in attentional skills contribute to the linguistic deficits that adults with aphasia experience (Murray 1999, 2000, Murray et al. 1997a, 1997b, 1998, Shisler 2005, Tseng et al. 1993, McNeil et al. 1991). Language processing requires an intact attention system in order to determine which information needs to be decoded as well as produced (Cahn and Polich 2006). A breakdown in attention can thus cause deficits at many points in language processing (Ramsberger 2005). Because language and attention are highly intertwined, and both are impaired in adults with aphasia, directly targeting attention in therapy may maximize recovery (Murray 1999, 2002). Murray and Ray (2001) provide some support for this idea using relaxation training to improve syntactic function in adults with aphasia. Further, patients who showed gains in language function also showed reduced negative affect (i.e., reduced anxiety, frustration and tension). Murray and Ray theorized that these mood-related changes helped free up attentional resources, allowing patients to focus on language processing (Murray 1999, 2002). Surprisingly, there are few treatments for aphasia that target attentional processing. Most treatments for aphasia focus on linguistic deficits (Helm-Estabrooks 2002), and attention deficits are often overlooked (Murray 2002). There is evidence of neurological and behavioural links between attention and language in adults with aphasia (Murray 1999, 2002). For this reason, exploring the effects of a MM programme on attention, as well as on language related outcomes, is important to the field of aphasia. The purpose of the current study is to explore the feasibility of teaching MM in a group format and to explore potential attention, language and physiological outcomes of MM in adults with aphasia. Other preliminary data have shown improvement in aphasia severity after other types of meditative training (Marshall and Laures-Gore 2008, Marshall and Panico 2008, Marshall 2008). Results of two previous case studies reporting use of MM in adults with aphasia are promising and suggest that exploration of its use with a group experimental design is warranted (Laures-Gore and Marshall 2016, Orenstein et al. 2012). Three central hypotheses for the current study include: (1) the attention deficits observed in adults with aphasia are amenable to MM, a technique that improves attentional focus; (2) improvement in attentional focus will result in improvement in language skills; and (3) MM will affect HRV, HR and salivary cortisol levels in people with aphasia. This study attempts: (1) to engage adults with aphasia in a brief MM programme in a group setting; (2) to collect preliminary measures on the effects of MM on attention and language; and (3) to assess physiological effects of MM for adults with aphasia by evaluating HRV, HR and salivary cortisol following MM training. HRV, HR and salivary cortisol are psychobiological markers of stress (Kirschbaum and Hellhammer 1994, Thayer et al. 2012) and are affected by MM (Lazar et al. 2005, Matousek et al. 2010). Methods Participants Ten participants attempted the study with two participants voluntarily withdrawing during the initial assessment phase due to travel constraints. Eight adults with aphasia (two African-American; six Caucasian) completed the current study (n = 8, five male, three female). The average age of the participants was 56.38 years (range 38 73 years) at the time of the study. Additional demographics, including pre-morbid handedness (three left, five right), educational background (12th grade to doctorate) and occupation were gathered through initial interview. Only adults more than 6 months postonset of stroke were included (range 1 year 3 months to 5 years) to allow for medical stabilization. The participants were not enrolled in any other aphasia treatment at the time of the study. Multiple strokes, head injury or other neurological disease served as exclusionary criteria, although one male participant had a history of head injury without reported residual deficits greater than 50 years prior. The participants were recruited in Atlanta and Athens, Georgia, through community support groups, speech and hearing treatment programmes, referrals and newspaper publicity. See table 1 for detailed participant description.

Mindfulness and aphasia 43 Table 1. Participant description Age (years) Sex Diagnosis Onset Hemi-paresis Handedness Education AQ Aphasia Training 1 73 Male Right CVA 5 years 3 months Left Left High school 71.8 Anomic (plus classes) 2 47 Male Left CVA 1 year 5 months None Right Bachelor 90.2 Anomic (plus classes) 3 70 Male Left CVA 3 years 3 months Right Right Doctorate 66.0 Anomic 4 62 Male Left CVA 1 year 9 months Right Left High school 10.2 Broca s 5 72 Female Left CVA 10 months None Right High school 69.0 Conduction Control 1 38 Female Left CVA 4 years Right Right Bachelor 85.1 Anomic 2 40 Female Left CVA 2 years 5 months Right Left Bachelor 93.2 Anomic 3 49 Male Left CVA 1 year 1 month Right Right High school a Anomic a Notes: AQ, Western Aphasia Battery Revised Aphasia Quotient; CVA, cerebral vascular accident. a Incomplete assessment. Figure 1. Study design. [Colour figure can be viewed at wileyonlinelibrary.com] Experimental design A within-subjects repeated-measure wait list control design was used to study the effects of MM on attention, language and physiological measures in adults with aphasia. This design allowed for incorporation of appropriate correlation structures to understand the effects of MM over time, while between-subject analyses allowed for comparisons between a training group (n = 5) and a wait list control group (n = (3) that did not receive treatment until a later phase of the study (two groups). The training group completed a total of four assessments: two baselines, post-5 days of MM training, and a follow-up assessment 1 week post. The wait list control group completed a total of five assessments: two baselines, after 5 days of mind wandering, a baseline prior to beginning the MM training and post-training (figure 1). All research procedures were approved by the University of Georgia and Georgia State University Institutional Review Boards. Measures The assessment battery and the MM training described briefly below have been previously reported in a case study (Laures-Gore and Marshall 2016) and were conducted in the same order for all participants (Western Aphasia Battery R, Conners Continuous Performance Test II, Centre for Research on Safe Driving-Attention Network Test, Naming, Personal Information, and Fluency, Generative Naming, Revised Token Test 5, and Word Productivity). Physiological measures were recorded during the group sessions only. Physiological measures provide objective data of the stress response and may circumvent some of the linguistic challenges encountered by adults with aphasia when completing self-report measures of stress. Initial assessment required completion of the Aphasia Quotient (AQ) from the Western Aphasia Battery R (WAB-R) to determine qualification. The WAB-R is a standardized, comprehensive language assessment of aphasia

44 Rebecca Shisler Marshall et al. (Kertesz 2006) whose psychometric properties are well documented (Shewan and Kertesz 1980) and can be used to document changes in language ability over time (Murray 2002). The AQ is a measure from the WAB-R that provides severity ratings for oral language (Shewan and Kertesz 1984). Word productivity and error frequency Word productivity and error frequency were calculated following the procedure described by Laures-Gore et al. (2010), Cherney et al. (1998) and Docherty et al. (1996). For the discourse task, participants were audio-recorded while providing a story depicted on the Helm-Estabrooks and Nicholas Narrative Story Cards (Helm-Estabrooks & Nicholas 2003). Word productivity is the proportion of productive words to total words for each 1 min of a language sample. The total number of words per minute was calculated by counting each word or word approximation (intelligible or unintelligible). Laures-Gore et al. (2010) have identified a potential use of word productivity as a behavioural indicator of stress when compared with cortisol levels. Error frequency is the total number of errors divided by the total number of productive words across each speech sample. Verbal fluency and length of utterance To measure verbal fluency and length of utterances, a guided language sample was collected from subtests of Aphasia Diagnostic Profiles (ADP; Patterson 2011). An initial question is presented to which the participant response was recorded digitally and in writing for analysis as a language sample and verbal fluency measure. People with aphasia frequently demonstrate difficulty with discourse tasks requiring language processing and cognitive processes (Shewan and Kertesz 1980). The following subtests were utilized: Naming, Personal Information and Fluency. The Generative Naming (verbal word production based on a category) subtest was also administered from the Cognitive Linguistic Quick Test and is criterion-referenced, and is reliable (CLQT; Helm-Estabrooks 2001). Auditory comprehension The five-item Revised Token Test (RTT) was used as a measure of receptive language processing and comprehension (Park et al. 2000) and is widely used in the aphasia population. The five-item RTT is a sensitive and descriptive assessment that consists of 10 subtests, which are rated on a 15-point scale, with varying difficulty and linguistic construction. Accuracy, responsiveness, completeness, promptness and efficiency are rated. Park et al. (2000) demonstrated the five-item version of the RTT reveals information consistent with that gained through theuseofthecompletertt. Attention measures In order to assess attention, both the Connors Continuous Performance Task II (CPT-II; Conners et al. 2000) and the CRSD-Attention Network Test (CRSD- ANT; Centre for Research on Safe Driving Attention Network Test; Weaver et al. 2013) were administered. The CPT-II (Conners et al. 2000, Conners 2004) is a computerized test tool to assess attention and neurological functioning. The CPT-II measures information related to inattentiveness (omissions, commissions, hit reaction time, hit standard error, detectability), impulsivity (commissions, hit reaction time, perseverations) and vigilance (hit reaction time block change, hit standard error block change). It has been normed on both healthy and neurologic populations and has the ability to detect clinical attention problems (Conners 2004). The CRSD-ANT is a 10-min version adapted from the ANT (Weaver et al. 2013). The ANT is utilized to evaluate attention problems in brain injury, stroke, schizophrenia and attention-deficit disorder (Fan et al. 2002) and the CRSD-ANT has been found to assess reliably the same attention components (Weaver et al. 2013). The CRSD-ANT provides information on three attentional networks: alerting, orienting and executive control. Similar to the ANT, the CRSD-ANT involves responding to the direction of an arrow target that is surrounded by flankers that point either in the same or opposite direction. Participants are instructed to respond as quickly as possible by pressing the left/right arrow key on the keyboard. The stimuli are nonverbal and have been used in previous research for individuals with aphasia (Laures-Gore and Marshall 2016). Psychophysiological measures HR and HRV (R-wave intervals) were used to quantify autonomic nervous system activity as they have been shown to respond to MM as demonstrated in other nonclinical populations (Burg et al. 2012). Both were collected using a Polar RS8000CX (Polar Electro OY, Kempele, Finland). HR and HRV were continuously recorded throughout the study at a sampling frequency of 1000 Hz, providing a temporal resolution of 1 ms for each R-R period (LabChart 7; ADInstruments, Toronto, ON, Canada). Salivary samples were collected to measure the stress hormone cortisol. Elevated cortisol has been associated with increased word productivity (Laures-Gore et al. 2010). Saliva samples were gathered by having each participant chew on a Salivette (Sarstedt, Rommelsdorf, Germany) for 1 min. A Salivette is a

Mindfulness and aphasia 45 commercially available device that provides hygienic saliva collection (Hellhammer et al. 1987). Each Salivette was coded for each participant, frozen at 80 C and later analyzed (Neuroscience Core Facility, Georgia State University, Atlanta, GA, USA) using a commercially prepared kit produced by Diagnostics Systems Laboratories (Webster, TX, USA). Procedure The participants completed informed consent and consented to video and audio recording. Due to recruitment and timing, multiple small groups participated and the procedure was completed a total of three times. Eight participants were assigned to groups (training or control) based on their ability to attend the scheduled sessions: training group A, n = 3; control group, n = 3; and training group B, n = 2. The project was conducted in the following order: training group A (n = 3); control group (n = 3); and training group B (n = 2). The two training groups were run using exactly the same procedure, but training was conducted on different dates. All participants completed a battery of assessments, as described above, twice prior to MM training/mind wandering (baselines 1 and 2). Assessment took place in a research laboratory associated with the first or second author (University of Georgia or Georgia State University). The assessor was a certified speech language pathologist and doctoral student, and was also responsible for participant recruitment. The test battery administered included: CPT-II, CRSD-ANT, WAB-R, Narrative Story Cards, ADP and RTT. Baseline 2 was completed 2 days after baseline 1 to establish baseline performance for all the participants, excluding the WAB-R, which was only given during baseline 1. One participant did not complete all components of the WAB due to experimenter error and therefore an AQ score was not calculated. After the baseline assessments, the participants completed five training sessions, which took place in the same research laboratory where the assessment was conducted. Participants assigned to the training group completed the Aphasia Mindfulness Meditation Program (see the appendix) with five sessions of MM (Monday Friday). Assessments of language and attention occurred pre- and post-mm training for a total of four assessments (two prior to training for baseline data, one immediately following MM on the final day and 1 week after MM). Participants assigned to the control group completed five sessions of mind wandering (Monday Friday). Assessments occurred pre- and post-mind wandering, and after a 5-day waitlist MM training programme. The control group completed a total of five assessments (two prior to training for baseline data, one immediately following mind wandering on the final day, post-waitlist, and after 1 week after mindfulness training). Both the training and control groups were led by the first author, a researcher and certified speech language pathologist with certifications in life coaching, yoga and specific training in mindfulness-based stress reduction (including leading groups, personal practice and research). HR measures were taken continuously during a 30-min period prior to group (training or control) during the group, and for 15 min following the group session (training or control). Saliva collection occurred at the end of each of those three periods. Both HR and saliva were only collected during the group meetings, and not during the assessments (pre-, post- or followup). Groups were conducted in the afternoon at the same time of day in an attempt to control for effects of the diurnal variation of cortisol. Training group The training group received guided MM training through a 5-day programme consisting of specific training and daily practise. Each meeting included a premeditation period (to collect baseline physiological data), instruction, practise, a post-meditation period (to collect physiological data), and discussion of difficulties and successes. The MM procedure, designed to enhance attention and present-moment awareness, was modelled after Laures-Gore and Marshall (2016), Kabat-Zinn (1982), Orenstein et al. (2012), Wenk- Sormaz (2005) and Zeidan et al. (2010). The Aphasia Mindfulness Meditation Program (see the appendix) included simplified instructions and graphic support was offered due to the language deficits associated with aphasia. MM participants were provided information that it is natural to be distracted and that the goal is to monitor attention continually and to focus attention on the breath, other sensations in the body and/or the aspects of the environment. MM instruction guided participants through a series of tasks while increasing the time spent in MM from 10 to 30 min, increasing by 5 or 10 min each day. This progression followed a predetermined duration with a particular rate increase. Participants were also instructed to practise MM at home on a daily basis, beginning with 10 min of MM and increasing to 30 min based on the instruction provided in the daily session. A guided MM CD was given to each participant to use at home during the study. Following a final MM session, participants completed the assessment battery again on day 5 of the training week, and 1 week post-completion, for a total of four assessment times. Control group The control group completed mind wandering daily for 5 days as a waitlist control. The same instructor led

46 Rebecca Shisler Marshall et al. Figure 2. Session design. [Colour figure can be viewed at wileyonlinelibrary.com] the control session and the participants were instructed to let their mind wander (to think about whatever) during the sessions in the control condition. Again, simplified instructions were provided due to the language deficits associated with aphasia. The progression of time and collection of physiological data followed the same parameters as the participants in the training group. Control group participants were assessed postmind wandering training, and 1 week post-completion of the control, to allow washout of any potential effects. Following completion of the control condition, all participants completed 5 days of MM training and a final assessment. See figures 1 and 2 for a depiction of both the study design and the session procedures. Data analysis Independent t-tests were conducted to compare the two groups with respect to age and aphasia quotient from the WAB-R. Repeated-measures analyses of variance were conducted using mixed-effects modelling in SAS 9.4 software (SAS, Cary, NC, USA) to determine if MM significantly changed attention, language and physiological measures among adults with aphasia. Correlation structures, typically compound symmetry or autoregressive (1) models, were used because exploratory analyses indicated they were necessary; several measures were natural log transformed to meet the normal distribution assumptions of the test. The language and attention measures were taken on each subject on four occasions; the physiological measures were taken on 4 separate days and multiple times each day, and therefore those statistical models include repeated time points within the day of measurement. When effects were found to be statistically significant in these models, post-hoc tests were included in the mixed-effects repeated-measures models in order to examine further the differences found. In addition to these tests, which compare the training group with the waitlist control group, correlations across the various measures used in the analyses were calculated and tested for statistical significance in order to examine the relationship across attention, language and physiological measures. A significance level of α = 0.05 is used throughout. Table 2. P-values from repeated-measures analysis of variance (ANOVA) comparing the natural log of the Aphasia Diagnostic Profiles subtest fluency scores of two groups over time Fluency Group Assessment Group Assessment p-value 0.9925 0.7247 0.0384 Table 3. Average aphasia diagnostic profile fluency score by group over four assessments Fluency Training Control assessment Mean SD Mean SD 1 7.60 3.62 10.34 4.24 2 8.99 4.54 7.64 1.43 3 10.79 7.08 6.56 2.99 4 9.07 5.65 8.35 4.71 Results Demographic comparison of the two groups Before analyses were conducted to determine the potential effects of MM on the measures investigated in the study, some of the demographic qualities of the two groups were compared using independent t-tests. The average age in the training group was somewhat higher than the average in the wait list control group, with greater than a 20-year difference. An independent t-test indicates that this difference was statistically significant (t(6) = 3.24, p = 0.0176; Cohen s d = 2.38). An independent t-test indicates no difference in the average WAB-R AQ of the two groups (t(5) = 1.22, p = 0.2760; Cohen s d = 1.02). Language measures All results reported here are from repeated-measures mixed-effect models. No significant differences in word productivity or error frequency were found between groups or over time. No significant differences were noted for RTT, either over time or between the two groups. No subtests from the ADP or CLQT showed significant differences between the groups (tables 2 and 3). Of note, post-hoc pairwise comparisons indicated that in the control group, but not in the training group, the

Mindfulness and aphasia 47 20.00 18.00 16.00 14.00 Fluency 1 12.00 10.00 8.00 Control Training 6.00 4.00 2.00 1 2 3 4 Assessment Number Figure 3. Aphasia Diagnostic Profiles Fluency for longest phrase, separately for two groups; bars represent ±1 SD. [Colour figure can be viewed at wileyonlinelibrary.com] fluency score from the ADP was significantly lower at assessment 3 than it was at assessment 1 (t(18) = 2.72, p = 0.0140), as shown in figure 3. The training group had the highest measure at assessment 3, but this was not statistically significant. Fluency gains were not maintained at follow-up. Attention measures Results reported here are from repeated-measures mixedeffect models. None of the measures taken using the CRSD-ANT was found to have any statistically significant differences, either over time or between the two groups. However, analysis of commissions (analyzed as natural log of commission percent) and detectability in the CPT-II were found to have statistically significant effects (see Table 4). The only statistically significant effect for commission percent is that both groups together significantly decreased their commission percentages over the course of the experiment (F(3,21) = 4.65, p = 0.0121). Post-hoc pairwise comparisons demonstrate that commissions are significantly lower at assessment 3 than assessment 1 (t(21) = 3.05, p = 0.0060) and at assessment 4 when compared with assessment 1 (t(21) = 3.72, p = 0.0013) and to assessment 2 (t(21) = 2.79, p = 0.0110). There are no significant differences across the two groups, however, and therefore this effect is not due to MM training. Differences in detectability are similar; the only statistically significant effect is that both groups together significant increased detectability over time (F(3,21) = 7.63, p = 0.0012). Post-hoc pairwise comparisons demonstrate that detectability is Table 4. P-values from repeated-measures analysis of variance (ANOVA) comparing Conners Continuous Performance Test II commission percentages of two groups over time Commissions model Group Assessment Group Assessment interaction Full 0.9808 0.0434 0.4858 Final 0.0121 significant higher at time 3 when compared with time 1 (t(21) = 3.79, p = 0.0011) and time 2 (t(21) = 2.28, p = 0.0329) and at time 4 when compared with time 1 (t(21) = 4.12, p = 0.0005) and time 2 (t(21) = 2.62, p = 0.0161). Physiological measures Results reported here are from repeated-measures mixedeffect models. HR was measured multiple times during each MM session (training group) or mind wandering session (control group). Average beats per minute (BPM) did not change over the sessions, nor did the pattern within sessions change over the sessions; however, within any given session, there were differences in the pattern over time of BPM within each group (significant interaction of group and time) (F(3,102) = 5.08, p = 0.0026). Post-hoc tests show that the training group showed no differences across times within a session, but the control group did show difference across times within a session (F(3,102) = 6.51, p = 0.0005). The control group BPM dropped continually over the

48 Rebecca Shisler Marshall et al. BPM session Table 5. Beats per minute (BPM) by group Session Training Control time point Mean SD Mean SD 1 1 65.20 16.90 75.00 5.57 2 65.00 15.94 70.33 4.04 3 66.40 17.87 71.67 5.51 4 63.00 14.28 72.33 4.73 2 1 55.50 8.27 92.50 10.61 2 55.00 7.97 87.50 10.61 3 55.60 8.62 81.00 5.66 4 54.40 7.92 76.00 2.83 3 1 57.80 11.65 76.50 0.71 2 56.60 8.53 73.00 2.83 3 56.60 9.40 69.50 2.12 4 56.00 8.43 72.00 0.00 4 1 62.25 9.00 103.67 54.10 2 60.20 10.13 77.33 18.50 3 61.80 10.03 76.67 16.56 4 60.80 9.28 74.33 10.50 session. While this did not occur in the training group, note that the control group had a significantly higher average BPM at the beginning of each session (F(1,102) = 12.50, p = 0.0006), which continued to be higher throughout the study (table 5 and figure 4). HR variability followed a pattern similar to BPM. No group effects were found in HRV. Post-hoc tests show that the training group showed no differences across time within a session (however, the control group did show difference across time within a session (F(3,104) = 9.43, p < 0.0001). Note that similarly to BPM (but in the opposite direction), HRV increased continuously across the sessions for the control group, but HRV was significantly lower on average in the control group than for the training group at the beginning of each session (F(1, 104) = 10.81, p = 0.0014), and this difference persisted throughout as shown in figure 5 (see also table 6). Cortisol was measured at three time points in each session. For analysis, the natural log of each cortisol measurement was calculated (see Table 7). There is an effect of time point within session that did not depend on the group (F(2,70) = 5.28, p = 0.0073). Post-hoc tests show that there are significant differences between time points 1 and 3 (t(70) = 3.04, p = 0.0033) and 2and3(t(70) = 2.82, p = 0.0062), but not between time points 1 and 2. Additionally, there is an interaction of group and session (F(3, 70) = 3.03, p = 0.0352), meaning that the average cortisol across the four sessions did not show the same pattern for each of the two groups. Post-hoc tests show that there are significant differences in average cortisol between sessions 1 and sessions 2 4 for the control group (t(70) = 2.57, p = 0.0124; t(70) = 2.08, p = 0.0412; and t(70) = 3.35, p = 0.0013, respectively), but there are no significant differences in average cortisol levels across sessions for the training group (see Table 8). As seen in figure 6, the control group started with a low average cortisol level in session 1, which increased to a level closer to the training group for the remaining sessions. It is not clear whether the initial 120 110 100 90 BPM 80 70 Control Training 60 50 40 1 2 3 4 Session Time Point Figure 4. Beats per minute (BPM) over session time points separately for two groups; bars represent ±1 SD. [Colour figure can be viewed at wileyonlinelibrary.com]

Mindfulness and aphasia 49 1200 1100 Heart Rate Variability 1000 900 800 Control Training 700 600 1 2 3 4 Session Time Point Figure 5. Heart rate variability over session time points separately for two groups; bars represent ±1 SD. [Colour figure can be viewed at wileyonlinelibrary.com] Table 6. Heart rate variability by group Heart rate variability Treatment Control Session Session time point Mean SD Mean SD 1 1 966.60 233.90 798.33 67.88 2 966.80 228.30 818.67 59.53 3 957.60 236.52 839.33 65.74 4 986.60 211.13 830.33 55.08 2 1 1100.25 149.82 654.00 73.54 2 1110.60 151.94 688.50 84.15 3 1097.40 158.77 743.50 47.38 4 1118.00 152.37 791.50 28.99 3 1 1065.20 192.54 784.50 0.71 2 1073.20 149.57 822.00 32.53 3 1081.00 165.57 861.00 22.63 4 1091.20 156.60 832.50 4.95 4 1 977.75 155.37 672.67 272.93 2 1017.60 179.50 804.33 195.83 3 996.00 164.52 805.67 169.57 4 1004.60 155.78 821.67 117.14 measure was particularly low, or whether this lower level of cortisol would have persisted without the group mindwandering practise. Correlations In addition to the repeated-measures analyses, some simple correlation analyses were run in order to determine whether the language, attention and physiological measures were related. Moreover, correlations were run to determine if the changes in these quantities Table 7. Cortisol by group Cortisol Training Control Session Session time point Mean SD Mean SD 1 1 6.69 3.49 3.43 1.79 2 6.62 2.85 3.38 2.08 3 5.41 1.90 3.61 1.88 2 1 5.98 1.35 6.00 1.70 2 5.86 1.73 6.59 2.46 3 5.52 2.09 5.00 2.86 3 1 5.62 2.85 5.41 1.64 2 5.02 2.53 4.80 1.91 3 4.64 1.76 4.52 2.32 4 1 6.27 1.72 7.10 2.85 2 7.23 4.61 6.72 3.21 3 6.86 5.44 5.57 3.35 over the course of the study were correlated across the participants. Change in the physiological measures was calculated from the second baseline measurement on day 1 to the third measurement (after MM for the training group, and after mind wandering for the control group) on day 4 (i.e., third measure on day 4 minus second baseline measure on day 1 for each participant). Changes in word productivity and error frequency were measured from the second baseline measurement of the study to the measurement taken immediately after all MM activities had been completed (or all mind wandering for the control group; i.e., post-mm/mind-wandering activities measure minus second baseline measure). The training group had statistically significant correlations

50 Rebecca Shisler Marshall et al. Table 8. P-values from repeated-measures analysis of variance (ANOVA) comparing ln(cortisol) of two groups over and within sessions Model Group Session Time Group Session Group Time Session Time Group Session Time Full 0.6346 0.0327 0.0081 0.0266 0.8902 0.5858 0.4341 Final 0.6261 0.0382 0.0073 0.0352 12 10 8 Cor sol 6 4 Control Training 2 0 1 2 3 4 Session Number Figure 6. Cortisol over sessions separately for two groups; bars represent ±1 SD. [Colour figure can be viewed at wileyonlinelibrary.com] between change in BPM and both word productivity (ρ = 0.9198, p = 0.0269) and error frequency (ρ = 0.9486, p = 0.0139). This group also had a statistically significant negative correlation between change in HRV and word productivity (ρ = 0.8839, p = 0.0467). No significant correlations were found in the control group. Discussion The purpose of this preliminary study was to explore the potential for individuals with aphasia to complete MM training, investigate potential attention and language changes that may occur with a brief training, and examine physiological changes that may occur with/out behavioural changes. In concurrence with previous research (Orenstein et al. 2012, Laures-Gore and Marshall 2016), findings suggest it is feasible to teach MM to adults with aphasia. With five training sessions, participants were able to increase time spent from 10 to 30 min in MM, both in the group setting and at home. Simplifying instructions and adding graphic support for adults with aphasia was possible and made MM feasible. This study is the first of its kind to measure HR, HRV and cortisol changes in adults with aphasia in a group format during MM training. Due to the exploratory nature of the study and the small sample size, limited statistical conclusions can be drawn. Current research in healthy populations suggests that attention changes are possible following brief MM training (Zeidan et al. 2010); however, there were no statistically significant changes on attention measures for the current sample of individuals with aphasia. In contrast, a few significant language changes were observed as a result of MM training for 5 days. Fluency was greater in the training group as compared with the control group at the third assessment, although the change was not maintained after a 1-week follow-up. While the control group decreased fluency, the training group increased fluency immediately after brief MM training. This is an interesting finding that suggests that training in MM may lead to increased fluency. Buchanan et al. (2014) have demonstrated that speech fluency (pauses) increases during acute stress conditions in a non-clinical population. The pausing demonstrated in the Buchanan et al. study could be related to a delay in word finding, which would coincide with the current findings.

Mindfulness and aphasia 51 Turning to the physiological data, the control group demonstrated a significant increase in cortisol from days 1 to 4 in comparison with the training group. After completing the study, the control group completed MM training sessions. After MM training the control group s cortisol did not increase unlike the pattern noted during mind wandering. This suggests that the mind wandering sessions resulted in activating the hypothalamic pituitary adrenal (HPA) axis more so than the MM sessions for the control group. The experimental design did not control for what types of thoughts one would conjure during the control session, so it is feasible that the mind wandering activity created a stress response in the control group; those receiving MM training, on the other hand, had encouragement to return to the breath and watch the thoughts without attachment. Within the training group, an association between HRV and word productivity could suggest that as HRV increases (more stress), word productivity decreases. However, caution interpreting this finding is advised given the individual results and that measures were not collected simultaneously, therefore the association could be spurious. As BPM increased during the training, word productivity increased and the error frequency decreased after the training. Previously, increased word productivity was related to increased cortisol levels suggesting that cortisol may be a necessary mobilizer for better language production in adults with aphasia (Laures-Gore et al. 2010). It is possible that the autonomic nervous system may be integral to productivity as well. Limitations While MM has been demonstrated as a method for increasing attentional capacity in the healthy population (Jha et al. 2007), we did not see changes specifically in attention in the training group for this preliminary study. This could be due to the selection of a brief training (5 days) as modelled after Zeidan et al. as opposed to the longer traditional training of meeting once a week for 8 weeks. More time in practice may be needed to make physiological and behavioural changes after stroke, or for these particular individuals. Moreover, the increase in performance observed on the attention task, found for both training and control groups, suggests the potential for practice effects for the CPT-II. While we did not see this change for other assessments, it calls into question the validity of using this assessment for such a brief training. Further, the degree of variability among participants, in addition to a small sample size, potentially affected both the behavioural and psychobiological results. The small sample size is a limitation of the study and definitely affects the power and conclusions in this study. In addition to the small sample size, there were several analyses and multiple comparisons performed on the same small dataset, which increases the chances of finding spurious results. Additionally, illness of some of the participants, transportation issues and equipment failure did occur and limited the analysis of the data collected. The HRV measures were also found to be consistently lower at baseline for the control group when compared with the training group, which suggests that these two groups were not comparable with respect to their HRV measures at baseline. At this early stage, randomization did not occur and this could have potentially influenced the makeup of the group. Future studies could potentially match participants based on HRV as well as the other measures this particular study utilized, or randomly assign individuals to groups. Subsequently, collection of language and attention measures should occur synchronously with additional physiological measures in order to make more conclusive findings about the relation between language and psychophysiological measures. Also, as a result of the preliminary nature of the study, the current study did not include subjective reports of mood and well-being measures which would permit analysis of mental health benefits that could emerge with MM training as has been shown with other clinical populations (Grossman et al. 2004). Due to mindfulness s potential benefits for managing anxiety and depression (Hofmann et al. 2010) and the high rates of depression with aphasia (Kauhanen et al. 2000), studying the effect of mindfulness on mood is an excellent direction for future research. In conclusion, adults with aphasia can learn MM and it may help to decrease the stress response and potentially increase verbal fluency; in this study, however, the increases in attention observed in the healthy aging population literature were not observed. While the change in fluency for the training group is interesting, the small sample size limits any generalizable results. MM has potential and possibility as a low-cost training, and it should continue to be studied to determine the specific contributions in adults with aphasia. Acknowledgements The research reported in this paper was supported by the Academy of Neurologic Communication Disorders and Sciences via the Collaborative Clinical Research Grant. References BUCHANAN, T. W., LAURES-GORE, J. S. andduff, M. C., 2014, Acute stress reduces speech fluency. Biological Psychology, 97, 60 66. BURG, J. M., WOLF, O. T. andmichalak, J., 2012, Mindfulness as self-regulated attention. Swiss Journal of Psychology, 71(3), 135 139.

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