See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/317704332

Brief mindfulness meditation group training in aphasia: Exploring attention,

language and psychophysiological outcomes

Article  in  International Journal of Language & Communication Disorders · June 2017

DOI: 10.1111/1460-6984.12325

CITATIONS READS

24 220

3 authors:

Rebecca Shisler Marshall Jacqueline Laures-Gore

University of Georgia Georgia State University
37 PUBLICATIONS   805 CITATIONS    54 PUBLICATIONS   1,368 CITATIONS   

SEE PROFILE SEE PROFILE

Kim Love
K. R. Love QCC
31 PUBLICATIONS   182 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Rebecca Shisler Marshall on 23 February 2022.

The user has requested enhancement of the downloaded file.

INT J LANG COMMUN DISORD, XXXX 2017,
VOL. 00, NO. 0, 1–15

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 individu-
als. 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
2 Rebecca Shisler Marshall et al.

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 measured by three aspects of attention: alerting, orient-

ing and conflict monitoring. Alerting has been described
According to the Centers for Disease Control (CDC),
as the basic wakefulness or arousal level, orienting in-
stroke is the leading cause of long-term disability in
volves selecting particular information, while conflict
adults in the United States with nearly 10% of adults
resolution consists of evaluating and resolving potential
over the age of 65 years surviving a stroke. The to-
thought, feeling, and response differences (Rueda et al.
tal cost of stroke-related expenditures from 2005 to
2005). Three groups of participants (no previous med-
2050 is projected to be US$1.52 trillion for non-
itation experience—control group, no previous medi-
Hispanic whites, US$313 billion for Hispanics and
tation experience—8-week MBSR course, and previous
US$379 billion for African-Americans (Wang et al.
experience in concentrative meditation—1-month re-
2014). These figures underscore the need for accessi-
treat) were measured pre- and post-training using the
ble, low-cost treatments of stroke-related disabilities. To
Attention Network Test (ANT; Fan et al. 2002). No sig-
address this need, the current study examines clinically
nificant difference between alerting and orienting types
relevant outcomes of a potentially low-cost interven-
of attention between the control group and experimental
tion for aphasia, a stroke-related disability, based on
groups was observed at baseline; however, a significantly
mindfulness meditation (MM). MM is a technique that
higher conflict monitoring performance was observed
improves self-regulation and cognitive control by fos-
for the experienced mediators. This confirmed the au-
tering different types of attention (Cahn and Polich
thors’ hypothesis that prior experience with meditation
2006, Rutschman 2004, Valentine and Sweet 1999).
may have long-term benefits for attention (Jha et al.
During MM, an individual directs the focus of at-
2007). At the conclusion of the training, the MBSR
tention to the breath. As focus begins to move to
group increased performance on conflict monitoring,
other thoughts or feelings, the individual is instructed
while the retreat group increased alerting performance.
to notice the shift in focus and redirect the focus
In other words, increasing practice increases the atten-
back to the breath (Teasdale et al. 1995). Over time,
tion performance and potentially different subtypes of
mindfulness is thought to increase the range of atten-
attention.
tional focus (Kabat-Zinn 1982). The effects of MM
Other studies have also demonstrated changes in
on cognitive performance, including attention regu-
the conflict monitoring subsystem of attention (Tang
lation, are well documented in neurologically typical
et al. 2007, Chan and Woollacott 2007, Moore and
adults (e.g., Valentine and Sweet 1999, Wenk-Sormaz
Malinowski 2009, Wenk-Sormaz 2005). For example,
2005).
MM has been shown to correlate with higher attentional
Several studies have demonstrated increased atten-
performance (Moore and Malinowski 2009) and may
tion following MM. For example, Valentine and Sweet
lead to improved selective attention as measured by the
(1999) compared the performance of 19 mediators (in-
Stroop task (Wenk-Sormaz 2005). Additionally, changes
cluding both concentrative and mindfulness techniques)
in the orienting subsystem have been observed following
and 24 controls on a sustained attention task. Both
MM training (MacCoon et al. 2014, MacLean et al.
groups of mediators performed more accurately than the
2010). Finally, changes in attentional blink following
controls on the sustained attention task, indicating that
MM have also been observed (Slagter et al. 2007, Van
meditation may have improved attention. Rutschman
Leeuwen et al. 2009, Van den Hurk et al. 2010; for a
(2004) compared the performance of two groups with
review, see also Tang et al. 2015).
differing MM experience (novice, practised with MM)
Furthermore, there is a growing body of evidence for
on a divided attention task. Performances of the two
neurophysiological changes during MM that are con-
groups indicated that both meditation and relaxation
sistent with modulation of attentional control (Cahn
improved attention capacity. However, the mediators’
and Polich 2006, Lazar et al. 2000, Manna et al. 2010,
performance increased significantly in comparison with
Zeidan et al. 2010). There is some evidence that even
the non-mediators. Rutschman further found that MM
short-term instruction in MM may improve attention,
improved participants’ abilities to shift attention rapidly
cognition and emotion (Zeidan et al. 2010, Tang et al.
between two tasks, as well as increase readiness.
2007). Tang et al. (2007) demonstrated improvements
Further, Jha et al. (2007) found effects
in attention and reductions in anxiety, depression, anger,
of mindfulness-based stress reduction (MBSR) as
fatigue and stress after 5 days of 20-min integrative
Mindfulness and aphasia
body–mind training (IBMT). Similarly, Zeidan et al.
(2010) found changes on tasks that require sustained at-
tention 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 atten-
tion and language skills are closely linked, and both
are impaired in aphasia (Murray 1999). Some earlier
studies have shown some encouraging results using re-
laxation or MM in persons with aphasia (PWA; Mar-
shall 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 stud-
ies are psychobiological assessment (cortisol, heart rate
(HR) and heart rate variability (HRV)), which would
offer potentially objective measures of the nervous sys-
tem. 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 con-
tribute 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 at-
tention system in order to determine which informa-
tion 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 inter-
twined, and both are impaired in adults with aphasia,
directly targeting attention in therapy may maximize re-
covery (Murray 1999, 2002). Murray and Ray (2001)
provide some support for this idea using relaxation train-
ing to improve syntactic function in adults with aphasia.
Further, patients who showed gains in language function
also showed reduced negative affect (i.e., reduced anxi-
ety, frustration and tension). Murray and Ray theorized
that these mood-related changes helped free up atten-
tional resources, allowing patients to focus on language
processing (Murray 1999, 2002). Surprisingly, there are
few treatments for aphasia that target attentional pro-
cessing. 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 atten-
tion 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
3
explore potential attention, language and physiologi-
cal outcomes of MM in adults with aphasia. Other
preliminary data have shown improvement in apha-
sia severity after other types of meditative training
(Marshall and Laures-Gore 2008, Marshall and
Panico 2008, Marshall 2008). Results of two previ-
ous 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 apha-
sia are amenable to MM, a technique that improves
attentional focus; (2) improvement in attentional fo-
cus will result in improvement in language skills; and
(3) MM will affect HRV, HR and salivary cortisol lev-
els 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 corti-
sol 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 partici-
pants voluntarily withdrawing during the initial assess-
ment phase due to travel constraints. Eight adults with
aphasia (two African-American; six Caucasian) com-
pleted 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 ini-
tial interview. Only adults more than 6 months post-
onset of stroke were included (range 1 year 3 months to
5 years) to allow for medical stabilization. The partici-
pants 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 cri-
teria, 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 sup-
port groups, speech and hearing treatment programmes,
referrals and newspaper publicity. See table 1 for detailed
participant description.
4 Rebecca Shisler Marshall et al.
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
a
3 49 Male Left CVA 1 year 1 month Right Right High school Anomica
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 Measures

A within-subjects repeated-measure wait list control de-
sign was used to study the effects of MM on atten-
tion, language and physiological measures in adults with
aphasia. This design allowed for incorporation of appro-
priate 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 assess-
ments: 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 base-
lines, 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.
The assessment battery and the MM training de-
scribed 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 In-
formation, and Fluency, Generative Naming, Revised
Token Test—5, and Word Productivity). Physiologi-
cal measures were recorded during the group sessions
only. Physiological measures provide objective data of
the stress response and may circumvent some of the lin-
guistic 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 standard-
ized, comprehensive language assessment of aphasia
Mindfulness and aphasia
(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 calcu-
lated 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 productiv-
ity 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 anal-
ysis 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 In-
formation and Fluency. The Generative Naming (ver-
bal 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 com-
prehension (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, com-
pleteness, promptness and efficiency are rated. Park et al.
(2000) demonstrated the five-item version of the RTT
5
reveals information consistent with that gained through
the use of the complete RTT.
Attention measures
In order to assess attention, both the Connors’ Con-
tinuous 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 neuro-
logical functioning. The CPT-II measures information
related to ‘inattentiveness’ (omissions, commissions, hit
reaction time, hit standard error, detectability), ‘impul-
sivity’ (commissions, hit reaction time, perseverations)
and ‘vigilance’ (hit reaction time block change, hit stan-
dard 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 re-
spond 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 associ-
ated with increased word productivity (Laures-Gore
et al. 2010). Saliva samples were gathered by hav-
ing each participant chew on a Salivette (Sarstedt,
Rommelsdorf, Germany) for 1 min. A Salivette is a
6 Rebecca Shisler Marshall et al.
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 Facil-
ity, 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 con-
sented 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 train-
ing 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 Uni-
versity). The assessor was a certified speech–language
pathologist and doctoral student, and was also respon-
sible for participant recruitment. The test battery ad-
ministered included: CPT-II, CRSD-ANT, WAB-R,
Narrative Story Cards, ADP and RTT. Baseline 2 was
completed 2 days after baseline 1 to establish base-
line 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 com-
pleted five training sessions, which took place in the
same research laboratory where the assessment was con-
ducted. Participants assigned to the training group com-
pleted 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). As-
sessments 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 fol-
lowing 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 (includ-
ing leading groups, personal practice and research).
HR measures were taken continuously during a
30-min period prior to group (training or control) dur-
ing the group, and for 15 min following the group ses-
sion (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 follow-
up). 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 train-
ing and daily practise. Each meeting included a pre-
meditation period (to collect baseline physiological
data), instruction, practise, a post-meditation period
(to collect physiological data), and discussion of dif-
ficulties 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) in-
cluded simplified instructions and graphic support was
offered due to the language deficits associated with apha-
sia. MM participants were provided information that it
is natural to be distracted and that the goal is to moni-
tor 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 du-
ration 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
Mindfulness and aphasia 7

Figure 2. Session design. [Colour figure can be viewed at wileyonlinelibrary.com]

the control session and the participants were instructed Table 2. P-values from repeated-measures analysis of variance
to let their ‘mind wander’ (to think about whatever) (ANOVA) comparing the natural log of the Aphasia Diagnostic
Profiles subtest fluency scores of two groups over time
during the sessions in the control condition. Again,
simplified instructions were provided due to the lan- Fluency Group Assessment Group × Assessment
guage deficits associated with aphasia. The progression
p-value 0.9925 0.7247 0.0384
of time and collection of physiological data followed
the same parameters as the participants in the training
Table 3. Average aphasia diagnostic profile fluency score by
group. Control group participants were assessed post- group over four assessments
mind wandering training, and 1 week post-completion
of the control, to allow washout of any potential effects. Fluency Training Control
Following completion of the control condition, all par- assessment Mean SD Mean SD
ticipants completed 5 days of MM training and a final
1 7.60 3.62 10.34 4.24
assessment. See figures 1 and 2 for a depiction of both 2 8.99 4.54 7.64 1.43
the study design and the session procedures. 3 10.79 7.08 6.56 2.99
4 9.07 5.65 8.35 4.71
Data analysis
Independent t-tests were conducted to compare the two Results
groups with respect to age and aphasia quotient from
Demographic comparison of the two groups
the WAB-R. Repeated-measures analyses of variance
were conducted using mixed-effects modelling in SAS Before analyses were conducted to determine the po-
9.4 software (SAS, Cary, NC, USA) to determine if MM tential effects of MM on the measures investigated in
significantly changed attention, language and physio- the study, some of the demographic qualities of the two
logical measures among adults with aphasia. Correlation groups were compared using independent t-tests. The
structures, typically compound symmetry or autoregres- average age in the training group was somewhat higher
sive (1) models, were used because exploratory analyses than the average in the wait list control group, with
indicated they were necessary; several measures were nat- greater than a 20-year difference. An independent t-test
ural log transformed to meet the normal distribution indicates that this difference was statistically significant
assumptions of the test. The language and attention (t(6) = 3.24, p = 0.0176; Cohen’s d = 2.38). An in-
measures were taken on each subject on four occasions; dependent t-test indicates no difference in the average
the physiological measures were taken on 4 separate days WAB-R AQ of the two groups (t(5) = –1.22, p =
and multiple times each day, and therefore those statis- 0.2760; Cohen’s d = 1.02).
tical models include repeated time points within the day
of measurement. When effects were found to be statis-
Language measures
tically significant in these models, post-hoc tests were
included in the mixed-effects repeated-measures models All results reported here are from repeated-measures
in order to examine further the differences found. In ad- mixed-effect models. No significant differences in word
dition to these tests, which compare the training group productivity or error frequency were found between
with the waitlist control group, correlations across the groups or over time. No significant differences were
various measures used in the analyses were calculated noted for RTT, either over time or between the two
and tested for statistical significance in order to examine groups. No subtests from the ADP or CLQT showed sig-
the relationship across attention, language and physio- nificant differences between the groups (tables 2 and 3).
logical measures. A significance level of α = 0.05 is used Of note, post-hoc pairwise comparisons indicated that
throughout. in the control group, but not in the training group, the
8 Rebecca Shisler Marshall et al.
20.00
18.00
16.00
14.00
Fluency 1
12.00
10.00
8.00
6.00
4.00
2.00
1 2
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 main-
tained at follow-up.
Attention measures
Results reported here are from repeated-measures mixed-
effect models. None of the measures taken using the
CRSD-ANT was found to have any statistically signif-
icant 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 to-
gether significantly decreased their commission percent-
ages over the course of the experiment (F(3,21) = 4.65,
p = 0.0121). Post-hoc pairwise comparisons demon-
strate that commissions are significantly lower at assess-
ment 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 detectabil-
ity over time (F(3,21) = 7.63, p = 0.0012). Post-hoc
pairwise comparisons demonstrate that detectability is
Control
Training
3 4
Table 4. P-values from repeated-measures analysis of variance
(ANOVA) comparing Conners’ Continuous Performance
Test—II commission percentages of two groups over time
Group ×
Commissions Assessment
model 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 mixed-
effect models. HR was measured multiple times during
each MM session (training group) or mind wander-
ing session (control group). Average beats per minute
(BPM) did not change over the sessions, nor did the
pattern within sessions change over the sessions; how-
ever, 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 ses-
sion, 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
Mindfulness and aphasia 9
Table 5. Beats per minute (BPM) by group (F(3,104) = 9.43, p < 0.0001). Note that similarly to
Training Control
BPM (but in the opposite direction), HRV increased
BPM Session continuously across the sessions for the control group,
session time point Mean SD Mean SD
but HRV was significantly lower on average in the con-
1 1 65.20 16.90 75.00 5.57 trol group than for the training group at the begin-
2 65.00 15.94 70.33 4.04 ning of each session (F(1, 104) = 10.81, p = 0.0014),
3 66.40 17.87 71.67 5.51 and this difference persisted throughout as shown in
4 63.00 14.28 72.33 4.73
figure 5 (see also table 6).
2 1 55.50 8.27 92.50 10.61
2 55.00 7.97 87.50 10.61
Cortisol was measured at three time points in each
3 55.60 8.62 81.00 5.66 session. For analysis, the natural log of each cortisol
4 54.40 7.92 76.00 2.83 measurement was calculated (see Table 7). There is an
3 1 57.80 11.65 76.50 0.71 effect of time point within session that did not depend
2 56.60 8.53 73.00 2.83 on the group (F(2,70) = 5.28, p = 0.0073). Post-hoc
3 56.60 9.40 69.50 2.12 tests show that there are significant differences between
4 56.00 8.43 72.00 0.00 time points 1 and 3 (t(70) = 3.04, p = 0.0033) and
4 1 62.25 9.00 103.67 54.10 2 and 3 (t(70) = 2.82, p = 0.0062), but not between
2 60.20 10.13 77.33 18.50
3 61.80 10.03 76.67 16.56
time points 1 and 2. Additionally, there is an interaction
4 60.80 9.28 74.33 10.50 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.
session. While this did not occur in the training group, Post-hoc tests show that there are significant differences
note that the control group had a significantly higher av- in average cortisol between sessions 1 and sessions 2–4
erage BPM at the beginning of each session (F(1,102) = for the control group (t(70) = –2.57, p = 0.0124; t(70)
12.50, p = 0.0006), which continued to be higher = –2.08, p = 0.0412; and t(70) = –3.35, p = 0.0013,
throughout the study (table 5 and figure 4). respectively), but there are no significant differences in
HR variability followed a pattern similar to BPM. average cortisol levels across sessions for the training
No group effects were found in HRV. Post-hoc tests group (see Table 8). As seen in figure 6, the control group
show that the training group showed no differences started with a low average cortisol level in session 1,
across time within a session (however, the control which increased to a level closer to the training group for
group did show difference across time within a session the remaining sessions. It is not clear whether the initial

120

110

100

90
BPM

80
Control

70 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]
10 Rebecca Shisler Marshall et al.
1200

Heart Rate Variability 1100

1000

900 Control
Training

800

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 Table 7. Cortisol by group

Heart rate variability Treatment Control Cortisol Training Control

Session Session time point Mean SD Mean SD Session Session time point Mean SD Mean SD

1 1 966.60 233.90 798.33 67.88 1 1 6.69 3.49 3.43 1.79

2 966.80 228.30 818.67 59.53 2 6.62 2.85 3.38 2.08
3 957.60 236.52 839.33 65.74 3 5.41 1.90 3.61 1.88
4 986.60 211.13 830.33 55.08 2 1 5.98 1.35 6.00 1.70
2 1 1100.25 149.82 654.00 73.54 2 5.86 1.73 6.59 2.46
2 1110.60 151.94 688.50 84.15 3 5.52 2.09 5.00 2.86
3 1097.40 158.77 743.50 47.38 3 1 5.62 2.85 5.41 1.64
4 1118.00 152.37 791.50 28.99 2 5.02 2.53 4.80 1.91
3 1 1065.20 192.54 784.50 0.71 3 4.64 1.76 4.52 2.32
2 1073.20 149.57 822.00 32.53 4 1 6.27 1.72 7.10 2.85
3 1081.00 165.57 861.00 22.63 2 7.23 4.61 6.72 3.21
4 1091.20 156.60 832.50 4.95 3 6.86 5.44 5.57 3.35
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 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
measure was particularly low, or whether this lower level third measurement (after MM for the training group,
of cortisol would have persisted without the group mind- and after mind wandering for the control group) on
wandering practise. day 4 (i.e., third measure on day 4 minus second base-
line measure on day 1 for each participant). Changes in
word productivity and error frequency were measured
Correlations
from the second baseline measurement of the study to
In addition to the repeated-measures analyses, some the measurement taken immediately after all MM ac-
simple correlation analyses were run in order to de- tivities had been completed (or all mind wandering for
termine whether the language, attention and physio- the control group; i.e., post-MM/mind-wandering ac-
logical measures were related. Moreover, correlations tivities measure minus second baseline measure). The
were run to determine if the changes in these quantities training group had statistically significant correlations
Mindfulness and aphasia 11
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
Corsol

6
Control
Training
4

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 productiv-
ity (ρ = 0.9198, p = 0.0269) and error frequency
(ρ = –0.9486, p = 0.0139). This group also had a sta-
tistically 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 lan-
guage changes that may occur with a brief training,
and examine physiological changes that may occur
with/out behavioural changes. In concurrence with pre-
vious 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 sta-
tistically significant changes on attention measures for
the current sample of individuals with aphasia. In con-
trast, 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 con-
trol 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 in-
creased fluency immediately after brief MM training.
This is an interesting finding that suggests that train-
ing 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.
12
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 wander-
ing 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 productiv-
ity 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 in-
creasing attentional capacity in the healthy population
(Jha et al. 2007), we did not see changes specifically in at-
tention 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 po-
tential 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 partici-
pants, 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
Rebecca Shisler Marshall et al.
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 conclu-
sive 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 po-
tentially increase verbal fluency; in this study, however,
the increases in attention observed in the healthy ag-
ing 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 Col-
laborative Clinical Research Grant.
References
BUCHANAN, T. W., LAURES-GORE, J. S. and DUFF, M. C., 2014,
Acute stress reduces speech fluency. Biological Psychology, 97,
60–66.
BURG, J. M., WOLF, O. T. and MICHALAK, J., 2012, Mindfulness
as self-regulated attention. Swiss Journal of Psychology, 71(3),
135–139.
Mindfulness and aphasia
CAHN, B. R. and POLICH, J., 2006, Meditation states and traits:
EEG, ERP, and neuroimaging studies. Psychological Bulletin,
132(2), 180–211.
CHAN, D. and WOOLLACOTT, M., 2007, Effects of level of med-
itation experience on attentional focus: is the efficiency of
executive or orientation networks improved? Journal of Alter-
native and Complementary Medicine, 13, 651–657.
CHERNEY, L. R., COELHO, C. A. and SHADDEN, B. B., 1998,
Analyzing Discourse in Communicatively Impaired Adults
(Aspen Publishers Inc.: Gaithersburg, Maryland).
CONNERS, C. K., 2004, Conners’ Continuous Performance Test, 2nd
edn (Toronto, ON: Multi Health Systems).
CONNERS, C. K., STAFF, M. H. S., CONNELLY, V., CAMPBELL, S.,
MACLEAN, M. and BARNES, J., 2000, Conners’ continuous
performance Test II (CPT II v. 5). Multi-Health Systems Inc.,
29, 175–196.
DOCHERTY, N. M., DEROSA, M. and ANDREASEN, N. C., 1996,
Communication disturbances in schizophrenia and mania.
Archives of General Psychiatry, 53(4), 358–364.
FAN, J., MCCANDLISS, B. D., SOMMER, T., RAZ, A. and POSNER, M. I.,
2002, Testing the efficiency and independence of attentional
networks. Journal of Cognitive Neuroscience, 14(3), 340–347.
GROSSMAN, P., NIEMANN, L., SCHMIDT, S. and WALACH, H.,
2004, Mindfulness-based stress reduction and health bene-
fits: a meta-analysis. Journal of Psychosomatic Research, 57(1),
35–43.
HELLHAMMER, D. H., KIRSCHBAUM, C. and BELKIEN, L., 1987, Mea-
surement of salivary cortisol under psychological stimulation.
Advanced Methods in Psychobiology, 281–289.
HELM-ESTABROOKS, N., 2001, Cognitive Linguistic Quick Test
(San Antonio, TX: The Psychological Corporation).
HELM-ESTABROOKS, N., 2002, Cognition and aphasia: a discussion
and a study. Journal of Communication Disorders, 35(2), 171–
186.
HELM-ESTABROOKS, N. and NICHOLAS, M., 2003, Narrative Story
Cards PRO-ED, Incorporated.
HOFMANN, S. G., SAWYER, A. T., WITT, A. A. and OH, D., 2010,
The effect of mindfulness-based therapy on anxiety and de-
pression: a meta-analytic review. Journal of Consulting and
Clinical Psychology, 78(2), 169–183.
JHA, A. P., KROMPINGER, J. and BAIME, M. J., 2007, Mindfulness
training modifies subsystems of attention. Cognitive, Affective,
and Behavioral Neuroscience, 7(2), 109–119.
KABAT-ZINN, J., 1982, An outpatient program in behavioral
medicine for chronic pain patients based on the practice of
mindfulness meditation: theoretical considerations and pre-
liminary results. General Hospital Psychiatry, 4(1), 33–47.
KAUHANEN, M. L., KORPELAINEN, J. T., HILTUNEN, P., MÄÄTTÄ, R.,
MONONEN, H., BRUSIN, E., SOTANIEMI, K. A. and MYLLYLÄ
V. V., 2000, Aphasia, depression, and non-verbal cognitive
impairment in ischaemic stroke. Cerebrovascular Disease, 10,
455–461.
KERTESZ, A., 2006, The Western Aphasia Battery (San Antonio, TX:
PsychCorp).
KIRSCHBAUM, C. and HELLHAMMER, D. H., 1994, Salivary cortisol
in psychoneuroendocrine research: recent developments and
applications. Psychoneuroendocrinology, 19(4), 313–333.
LAURES-GORE, J. S., DUBAY, M. F., DUFF, M. C. and BUCHANAN, T.
W., 2010, Identifying behavioral measures of stress in indi-
viduals with aphasia. Journal of Speech, Language, and Hearing
Research, 53(5), 1394–1400.
LAURES-GORE, J. and MARSHALL, R. S., 2016, Mindfulness medi-
tation in aphasia: a case report. NeuroRehabilitation, 38(4),
321–329.
LAZAR, S. W., BUSH, G., GOLLUB, R. L., FRICCHIONE, G. L., KHALSA,
G. and BENSON, H., 2000, Functional brain mapping of
13
the relaxation response and meditation. Neuroreport, 11(7),
1581–1585.
LAZAR, S. W., KERR, C. E., WASSERMAN, R. H., GRAY, J. R., GREVE,
D. N., TREADWAY, M. T., MCGARVEY, M., QUINN, B. T.,
DUSEK, J. A., BENSON, H. and RAUCH, S. L., 2005, Medita-
tion experience is associated with increased cortical thickness.
Neuroreport, 16(17), 1893–1897.
MACCOON, D. G., MACLEAN, K. A., DAVIDSON, R. J., SARON, C.
D. and LUTZ, A., 2014, No sustained attention differences
in a longitudinal randomized trial comparing mindfulness
based stress reduction versus active control. PLOS ONE, 9(6),
e97551.
MACLEAN, K. A., FERRER, E., AICHELE, R. S., BRIDEWELL, D.,
ZANESCO, A., JACOBS, L. T., KING, B., ROSENBURG, L. E.,
SAHDRA, B., SHAVER, R. P., WALLACE, A., MANGUN, R. G.
and SARON, C., 2010, Intensive meditation training improves
perceptual discrimination and sustained attention. Psycholog-
ical Science, 21(6), 829–839.
MANNA, A., RAFFONE, A., PERRUCCI, M. G., NARDO, D., FERRETTI,
A., TARTARO, A., LONDEI, A., DEL GRATTA, C., BELARDINELLI,
M. O. and ROMANI, G. L., 2010, Neural correlates of focused
attention and cognitive monitoring in meditation. Brain Re-
search Bulletin, 82(1), 46–56.
MARSHALL, R. S., BASILAKOS, A., WILLIAMS, T. and LOVE-MYERS,
K., 2014, Exploring the benefits of unilateral nostril breath-
ing practice post-stroke: Attention, language, spatial abilities,
depression, and anxiety. The Journal of Alternative and Com-
plementary Medicine, 20(3), 185–194.
MARSHALL, R. S. and LAURES-GORE, J., 2008, CE introduction: what
is complementary and alternative medicine? SIG 2 Perspectives
on Neurophysiology and Neurogenic Speech and Language Dis-
orders, 18(3), 86–89.
MARSHALL, R. S. and PANICO, R., 2008, A pilot study on the effect of
unilateral nostril breathing following stroke. In Proceedings of
the 36th Annual Meeting of the International Neuropsychological
Society. February, 2008. Hawaii.
MARSHALL, R. C. and WATTS, M. T., 1976, Relaxation train-
ing: effects on the communicative ability of aphasic adults.
Archives of Physical Medicine and Rehabilitation, 57(10),
464–467.
MATOUSEK, R. H., DOBKIN, P. L. and PRUESSNER, J., 2010, Cortisol
as a marker for improvement in mindfulness-based stress re-
duction. Complementary Therapies in Clinical Practice, 16(1),
13–19.
MCNEIL, M. R., ODELL, K. and TSENG, C. H., 1991, Toward the
integration of resource allocation into a general theory of
aphasia. Clinical Aphasiology, 20, 21–39.
MCNEIL, M. R. and PRESCOTT, T. E., 1978, Revised Token Test
(Austin, TX. Pro-ed).
MOORE, A. AN MALINOWSKI, P., 2009, Meditation, mindfulness and
cognitive flexibility. Consciousness and Cognition, 18, 176–
186.
MURRAY, L. L., 1999, Review attention and aphasia: Theory, research
and clinical implications. Aphasiology, 13(2), 91–111.
MURRAY, L. L., 2000, The effects of varying attentional demands
on the word retrieval skills of adults with aphasia, right hemi-
sphere brain damage, or no brain damage. Brain and Lan-
guage, 72(1), 40–72.
MURRAY, L. L., 2002, Attention deficits in aphasia: presence, nature,
assessment, and treatment. Seminars in Speech and Language,
23(2), 107–116.
MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1997a, Ac-
curacy monitoring and task demand evaluation in aphasia.
Aphasiology, 11(4–5), 401–414.
MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1997b, Audi-
tory processing in individuals with mild aphasia: a study of
14
resource allocation. Journal of Speech, Language, and Hearing
Research, 40(4), 792–808.
MURRAY, L. L., HOLLAND, A. L. and BEESON, P. M., 1998, Spo-
ken language of individuals with mild fluent aphasia under
focused and divided-attention conditions. Journal of Speech,
Language, and Hearing Research, 41(1), 213–227.
MURRAY, L. L. and RAY, A. H., 2001, A comparison of relaxation
training and syntax stimulation for chronic nonfluent aphasia.
Journal of Communication Disorders, 34(1), 87–113.
ORENSTEIN, E., BASILAKOS, A. and MARSHALL, R. S., 2012, Effects of
mindfulness meditation on three individuals with aphasia. In-
ternational Journal of Language and Communication Disorders,
47(6), 673–684.
PATTERSON, J., 2011, Aphasia diagnostic profiles. In Encyclopedia of
Clinical Neuropsychology (New York: Springer), pp. 223–225.
PARK, G. H., MCNEIL, M. R. and TOMPKINS, C. A., 2000, Reliabil-
ity of the five-item Revised Token Test for individuals with
aphasia. Aphasiology, 14(5–6), 527–535.
RAMSBERGER, G., 2005, Achieving conversational success in aphasia
by focusing on non-linguistic cognitive skills: a potentially
promising new approach. Aphasiology, 19(10–11), 1066–
1073.
RUEDA, M. R., POSNER, M. I. and ROTHBART, M. K., 2005, The
development of executive attention: contributions to the
emergence of self-regulation. Developmental Neuropsychology,
28(2), 573–594.
RUTSCHMAN, J. R., 2004, Effects of techniques of receptive med-
itation and relaxation on attentional processing. Canadian
Undergraduate Journal of Cognitive Science, 7, 6–16.
SHEWAN, C. M. and KERTESZ, A., 1980, Reliability and validity
characteristics of the Western Aphasia Battery (WAB). Journal
of Speech and Hearing Disorders, 45(3), 308–324.
SHEWAN, C. M. and KERTESZ, A., 1984, Effects of speech and lan-
guage treatment on recovery from aphasia. Brain and Lan-
guage, 23(2), 272–299.
SHISLER, R., 2005, Aphasia and auditory extinction: preliminary
evidence of binding. Aphasiology, 19(7), 633–650.
SLAGTER, H. A., LUTZ, A., GREISCHAR, L. L., FRANCIS, D. A.,
NIEUWENHUIS, S., DAVIS, M. J. and DAVIDSON, J. R., 2007,
Mental training affects distribution of limited brain resources.
PLOS Biology, 5(6), e138.
TANG, Y. Y., HOLZEL, B. K. and POSNER, M. I., 2015, The neu-
roscience of mindfulness meditation. Nature Reviews Neuro-
science, 16, 213–225.
TANG, Y. Y., MA, Y., WANG, J., FAN, Y., FENG, S., LU, Q., YU,
Q., SUI, D., ROTHBART, M. K., FAN, M. and POSNER, M. I.,
2007, Short-term meditation training improves attention and
self-regulation. Proceedings of the National Academy of Sciences,
USA, 104(43), 17152–17156.
TEASDALE, J. D., SEGAL, Z. and WILLIAMS, J. M. G., 1995, How does
cognitive therapy prevent depressive relapse and why should
attentional control (mindfulness) training help? Behaviour
Research and Therapy, 33(1), 25–39.
THAYER, J. F., ÅHS, F., FREDRIKSON, M., SOLLERS, J. J. and WAGER,
T. D., 2012, A meta-analysis of heart rate variability and
neuroimaging studies: Implications for heart rate variability
as a marker of stress and health. Neuroscience and Biobehavioral
Reviews, 36(2), 747–756.
TSENG, C. H., MCNEIL, M. R. and MILENKOVIC, P., 1993, An inves-
tigation of attention allocation deficits in aphasia. Brain and
Language, 45(2), 276–296.
VALENTINE, E. R. and SWEET, P. L., 1999, Meditation and attention:
a comparison of the effects of concentrative and mindfulness
meditation on sustained attention. Mental Health, Religion
and Culture, 2(1), 59–70.
Rebecca Shisler Marshall et al.
VAN DEN HURK, P. A., GIOMMI, F., GIELEN, S. C., SPECKENS, A. E.
M. and BARENDREGT, H. P., 2010, Greater efficiency in atten-
tional processing related to mindfulness meditation. Quarterly
Journal of Experimental Psychology, 63, 1168–1180.
VAN LEEUWEN, S., WILLER, N. G. and MELLONI, L., 2009, Age
effects on attentional blink performance in meditation. Con-
sciousness and Cognition, 18, 593–599.
WEAVER, B., BÉDARD, M. and MCAULIFFE, J., 2013, Evaluation of
a 10-minute version of the attention network test. Clinical
Neuropsychologist, 27(8), 1281–1299.
WENK-SORMAZ, H., 2005, Meditation can reduce habitual respond-
ing. Alternative Therapies in Health and Medicine, 11(2), 42–
58.
WANG, G., ZHANG, Z., AYALA, C., DUNET, D. O., FANG, J. and
GEORGE, M. G., 2014, Costs of hospitalization for stroke
patients aged 18–64 years in the United States. Journal of
Stroke and Cerebrovascular Diseases, 23(5), 861–868.
ZEIDAN, F., JOHNSON, S. K., DIAMOND, B. J., DAVID, Z. and
GOOLKASIAN, P., 2010, Mindfulness meditation improves
cognition: Evidence of brief mental training. Consciousness
and Cognition, 19(2), 597–605.
Appendix: Aphasia Mindfulness Meditation
Program
The Aphasia Mindfulness Meditation Program is
derived from the traditional trainings of mindfulness, as
well as from other mindfulness research (Jha et al. 2007,
Zeidan et al. 2010), but adapted to the clinical challenges
of aphasia similar to previous studies (Orenstein et al.
2012, Laures-Gore and Marshall 2016).
Due to potential difficulty with attention and fatigue
in aphasia, each training session lasted about 30 min.
The focus for this study was simply on breath awareness
and present moment awareness in mindfulness med-
itation (MM) due to the benefits of mindfulness on
training attention.
The structure of a session focused on the practice
of drawing the attention to a particular focus, and then
returning the attention to that focus multiple times over
the course of the session. Sessions emphasize finding a
comfortable position, but not to fall asleep. Focus on the
breath at the nose, chest or belly and bringing the aware-
ness the present moment. Participants were informed
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. The concept that mindful-
ness/attention is a muscle that needs to be strengthened
was repeated throughout the sessions. Participants were
asked to practise the MM focusing on breath awareness
on a daily basis outside of the session as well.
Finally, language was simplified to increase
likelihood of auditory comprehension. A pictorial in-
struction sheet was provided on the first day to facilitate
understanding of the practice. One individual did have
some comprehension deficits, and therefore the MM
training included gestures, more detailed demonstration
Mindfulness and aphasia
and other visual cues to complement the auditory
instructions. The Aphasia Mindfulness Meditation
Program was facilitated by a certified speech–language
pathologist with training and experience in MM and
mindfulness based stress reduction.
Session 1: Introduction to mindfulness, and practise for
10 min
r Introduction to mindfulness.
r Information on how and when to practise (quiet
place, free from distractions, body positioning).
r Awareness of the breath, including picking a spe-
cific location to focus on the breath (nose, chest,
belly).
r Direction on compassionate redirection if the at-
tention wanders.
r Discuss experiences from the session. Time for
questions.
Homework goal = 10 min of MM.
Session 2: Mindfulness meditation for 15 min
r Discuss questions and ask about the practice.
Discuss the obstacles and celebrate any and all
successes.
r Guided meditation on awareness of the breath,
including picking a specific location to focus on
the breath (nose, chest, belly).
r Direction on compassionate redirection if the at-
tention wanders.
r Discuss experiences from the session. Ask about
the practice. Discuss the obstacles and celebrate
any and all successes.
r With a longer meditation practice, the guidance is
to continue to notice the breath, but that thoughts
(distractions, pain, boredom etc.) may be more
prominent. Discussion included regarding how
this does not mean anything, just an opportunity
to notice and bring attention back to the present
moment using the breath or sensations in the body
or a sound.
View publication stats
15
r Direction on compassionate redirection if the at-
tention wanders
r Discuss experiences from the session. Time for
questions.
Homework goal = 15 min of MM.
Session 3: Increase time on mindfulness meditation to
20 min
r Discuss experiences from the previous sessions.
Ask about the practice. Discuss the obstacles and
celebrate any and all successes.
r Continue with guided meditation on awareness of
the breath, including picking a specific location to
focus on the breath (nose, chest, belly).
r As the meditation lengthens, offer more guidance
on returning the breath and the present moment
to centre stage.
r Discuss experiences from the session. Time for
questions.
Homework goal = 20–25 min of MM.
Session 4: Increase time with mindfulness meditation
to 30 min
r Discuss experiences from the previous sessions.
Ask about the practice. Discuss the obstacles and
celebrate any and all successes.
r Continue with guided meditation on awareness
of the breath, including picking a specific location
to focus on the breath (nose, chest, belly). Longer
spans of silence, with continued reinforcement
of compassionate redirection when the attention
wanders.
r Discuss experiences from the session. Time for
questions.
Homework goal = 30 min of MM.
Session 5: 30 min of mindfulness meditation, without
guidance, prior to post-assessment battery