Intensive Aphasia Therapy and Constraint Induced Therapy for Aphasia: A Discussion of Current Evidence and Clinical Experience Gail Lommen MS CCC-SLP North Memorial 763-520-7375 [email_address]

Tissue Plasminogen Activator (t-PA) 1997 Product of recombinant DNA technology Activity may last for several hours once bound to a clot

Product of recombinant DNA technology

Activity may last for several hours once bound to a clot

Interventional Stroke Therapy

Intra-Arterial Thrombolysis

Carotid Stents Angiogram Percutaneous balloon angioplasty Placement of stent in the carotid artery

Angiogram

Percutaneous balloon angioplasty

Placement of stent in the carotid artery

Stroke Prevalence 730,000 strokes per year 160,000 deaths a year Third leading cause of death 4,000,000 stroke survivors Leading cause of adult disability Source: Stroke Facts: NSA 2004

730,000 strokes per year

160,000 deaths a year

Third leading cause of death

4,000,000 stroke survivors

Leading cause of adult disability

Introduction What do stroke survivors with apashia want? 1- Meet others with aphasia "Speak Easy" "Coffee and Conversation"

What do stroke survivors with apashia want?

1- Meet others with aphasia

"Speak Easy"

"Coffee and Conversation"

Introduction 2- MORE THERAPY!

2- MORE THERAPY!

Constraint Induced Aphasia Therapy

Write down one way you might implement these concepts into your clinical practice.

Write down one way you might implement these concepts into your clinical practice.

Constraint Induced Aphasia Therapy (CIAT) (general outline for our discussion) History and evidence Basic Principles Trends Intense Aphasia Therapy at North Memorial 2002-2009 Issues and future trends

History and evidence

Basic Principles

Trends

Intense Aphasia Therapy at North Memorial 2002-2009

Issues and future trends

CIAT History and Evidence History and evidence a. Benefits of therapy in the late/"chronic" stages of recovery b. Regular versus Intense therapy c. Constraint Induced Aphasia Therapy

History and evidence

a. Benefits of therapy in the late/"chronic" stages of recovery

b. Regular versus Intense therapy

c. Constraint Induced Aphasia Therapy

CIAT History and Evidence Sheehan (1947, 1948) Made the case for additional management of soldiers with aphasia who were dismissed from military care. She outlined the need for analysis and intervention that is tailored to the individual and would include intensity.

Sheehan (1947, 1948)

Made the case for additional management of soldiers with aphasia who were dismissed from military care. She outlined the need for analysis and intervention that is tailored to the individual and would include intensity.

CIAT History and Evidence Schuell 1964 Auditory/sensory stimulation affects brain activity Repeated stimulation is essential for acquisition, organization, storage and retrieval

Schuell 1964

Auditory/sensory stimulation affects brain activity

Repeated stimulation is essential for acquisition, organization, storage and retrieval

CIAT History and Evidence Poeck (1989) Investigated whether intensive language oriented therapy (versus functional) lead to improvement beyond the rate of spontaneous recovery and whether it is effective beyond 12 months post.

Poeck (1989)

CIAT History and Evidence Poeck (cont) 76 patients received 9 hours of therapy per week over a period of 6-8 weeks. With intensive therapy, improvement went beyond what is expected with spontaneous recovery (92 controls in a previous study who had not received Tx) in 78% of the patients treated up to 4 months and 46% of those treated from 4-12 months.

Poeck (cont)

CIAT History and Evidence Mackenize (1991) Attempting to lend support for tx in general, she concluded that researchers who did not find tx to be beneficial were typically provided fewer than 50 hours…. N=5, All had been D/C from Tx (>9mpo). All 4 had 1 month of no Tx, 4 weeks of Intense Tx (2-3 hours per day), and then no treatment. Skills were gained and maintained.

Mackenize (1991)

Attempting to lend support for tx in

general, she concluded that researchers

who did not find tx to be beneficial were

typically provided fewer than 50 hours….

N=5, All had been D/C from Tx (>9mpo). All 4 had

1 month of no Tx, 4 weeks of Intense Tx (2-3 hours

per day), and then no treatment. Skills were gained

and maintained.

CIAT History and Evidence Conclusion: Gains were made in one month that one might otherwise make if Tx were spread out over one year.

Conclusion:

Gains were made in one month that one might otherwise make if Tx were spread out over one year.

CIAT History and Evidence Robey, R. R. (1994). The efficacy of treatment for aphasic persons: A meta-analysis. Brain and Language, 47, 582-608. Meta Analysis of aphasia literature revealed large effect sizes with Tx provided for 2 or more hours per week.

Robey, R. R. (1994). The efficacy of treatment for aphasic persons: A meta-analysis. Brain and Language, 47, 582-608.

Meta Analysis of aphasia literature revealed large effect sizes with Tx provided for 2 or more hours per week.

CIAT History and Evidence Denes, Perazzolo, Piani & Piccione (1996) Compared intensive therapy (daily) versus regular (3x/week) in a group of patients with global aphasia . Following therapy, both groups showed significant improvement in language. Those receiving intensive therapy showed the more favorable outcome.

Denes, Perazzolo, Piani & Piccione (1996)

Compared intensive therapy (daily) versus regular (3x/week) in a group of patients with global aphasia .

Following therapy, both groups showed significant improvement in language. Those receiving intensive therapy showed the more favorable outcome.

CIAT History and Evidence Hinckley, Craig (1998) Found significant gains in naming after intense therapy vs no treatment and various rates of non-intensive therapy. Therapy provided three hours per week or less was similar to the effect of no therapy.

Hinckley, Craig (1998)

Found significant gains in naming after intense therapy vs no treatment and various rates of non-intensive therapy. Therapy provided three hours per week or less was similar to the effect of no therapy.

CIAT History and Evidence Dr. Edward Taub University of Alabama, Birmingham Taub, E. Crago, J. E. Uswatte, G (1998). Constraint-Induced Movement Therapy: A New Approach to Treatment in Physical Rehabilitation. VOL 43; NUMBER 2, pages 152-170. http://wikicafe.metacafe.com/en/BlazerCast_for_4/22/08

Dr. Edward Taub

University of Alabama, Birmingham

Taub, E. Crago, J. E. Uswatte, G (1998). Constraint-Induced Movement

Therapy: A New Approach to Treatment in Physical Rehabilitation. VOL

43; NUMBER 2, pages 152-170.

http://wikicafe.metacafe.com/en/BlazerCast_for_4/22/08

CIAT History and Evidence Dr. Edward Taub (1998) Cortical mapping Learned non-use Motor behavior is modifiable – "Use it to improve it" Constraints Massed practice 120 published studies including a single-site, placebo-controlled trial (Taub, 2006) and a large multisite randomized trial (Wolf, 2006).

Dr. Edward Taub (1998)

Cortical mapping

Learned non-use

Motor behavior is modifiable – "Use it to improve it"

Constraints

Massed practice

120 published studies including a single-site, placebo-controlled trial (Taub, 2006) and a large multisite randomized trial (Wolf, 2006).

CIAT History and Evidence Pradat-Diehl, Tessier (2001) Present a case of deferred and long term recovery. Therapy began 10 months post stroke with no prior therapy. Gains were reported for at least 6 years.

Pradat-Diehl, Tessier (2001)

Present a case of deferred and long term recovery. Therapy began 10 months post stroke with no prior therapy. Gains were reported for at least 6 years.

CIAT History and Evidence Pulvermuller et al 2001 "Constraint Induced Aphasia Therapy“ Basic Principles Constrain/forced use Concentrated Massed-Practice Shaping Relevance Therapeutic games

Pulvermuller et al 2001

"Constraint Induced Aphasia Therapy“

Basic Principles

Constrain/forced use

Concentrated Massed-Practice

Shaping

Relevance

Therapeutic games

CIAT History and Evidence Methods: 17 patients with chronic aphasia Randomly assigned to conventional therapy (CT) or CIAT Patients did not differ significantly other than time post stroke. CI group was further post stroke than CT. This was an unforeseeable consequence of the randomization and would likely be considered a disadvantage to the CI group.

Methods:

17 patients with chronic aphasia

Randomly assigned to conventional therapy (CT) or CIAT

Patients did not differ significantly other than time post stroke. CI group was further post stroke than CT. This was an unforeseeable consequence of the randomization and would likely be considered a disadvantage to the CI

group.

CIAT History and Evidence CIAT = 3-4 hours per day x10days (avg of 31.5 total hours) CT = 1 hour per day for 3-5 weeks (avg of 33.9 total hours)

CIAT = 3-4 hours per day x10days (avg of 31.5 total hours)

CT = 1 hour per day for 3-5 weeks (avg of 33.9 total hours)

CIAT History and Evidence CIAT: Materials 32 cards with 16 pictures (common name or high frequency word or tailored to individual needs i.e. minimal pairs sock/rock, white/black) Hierarchy for requests/constrain Name Article or designated object Syntactically correct sentence Reinforcement per expectation of the patient- be clear on what is expected

CIAT:

Materials

32 cards with 16 pictures (common name or high

frequency word or tailored to individual needs i.e.

minimal pairs sock/rock, white/black)

Hierarchy for requests/constrain

Name

Article or designated object

Syntactically correct sentence

Reinforcement per expectation of the patient- be clear on what is expected

CIAT History and Evidence CT: Syndrome specific methods considered standard in Germany including interventions such as naming, repetition, sentence completion, following instructions, conversations on topics of the patient's choice, training of various communicative methods.

CT:

Syndrome specific methods considered

standard in Germany including interventions

such as naming, repetition, sentence

completion, following instructions,

conversations on topics of the patient's choice,

training of various communicative methods.

CIAT History and Evidence Outcomes Aachen Aphasia Battery Significant improvement for CI group (17%) No significant improvement for CT (2%) Communication in everyday life: 30% increase for CI 0% reported for CT

Outcomes

Aachen Aphasia Battery

Significant improvement for CI group (17%)

No significant improvement for CT (2%)

Communication in everyday life:

30% increase for CI

0% reported for CT

CIAT History and Evidence Agree that plateau exists within first year post stroke. Scattered reports indicate that therapy can produce improvements after the first year but in these reports, tx was provided for many hours over an extensive period.

Agree that plateau exists within first year post stroke.

Scattered reports indicate that therapy can produce improvements after the first year but in these reports, tx was provided for many hours over an extensive period.

CIAT History and Evidence Future research should investigate: Whether even more intense Tx can further improve outcome Whether outcomes are maintained for long periods Whether outcomes differ between patient profiles i.e. aphasia types, psychiatric issues an in what ways the components of CI contribute to the outcome.

Future research should investigate:

Whether even more intense Tx can further improve outcome

Whether outcomes are maintained for long periods

Whether outcomes differ between patient profiles i.e. aphasia types, psychiatric issues an in what ways the components of CI contribute to the outcome.

CIAT History and Evidence Bhogal, Teassell, Speechley, Albert (2003) Intensity of Aphasia Therapy, Impact on Recovery- Aphasia therapy works “ lower-intensity over a long period of time does not result in a significant change in outcome. However, more intensive SLT, delivered over a shorter period of time, results in significant improvements in outcome.” “ It is only by radically reorganizing current provision or increasing the time allocated to speech therapists that their expertise can be effective in the field of chronic aphasia”

Bhogal, Teassell, Speechley, Albert (2003)

Intensity of Aphasia Therapy, Impact on Recovery- Aphasia therapy works

“ lower-intensity over a long period of time does not result in a significant change in outcome. However, more intensive SLT, delivered over a shorter period of time, results in significant improvements in outcome.”

“ It is only by radically reorganizing current provision or increasing the time allocated to speech therapists that their expertise can be effective in the field of chronic aphasia”

CIAT History and Evidence Meizner 2005 Examined the efficacy of a short-term, intensive language training, constraint-induced aphasia therapy (CIAT) and CIAT-Plus.

Meizner 2005

Examined the efficacy of a short-term, intensive language training, constraint-induced aphasia therapy (CIAT) and CIAT-Plus.

CIAT History and Evidence Maher (2006) Intense therapy for verbal versus non-verbal interventions.

Maher (2006)

Intense therapy for verbal versus non-verbal interventions.

CIAT History and Evidence Cherney, Patterson, Raymer, Frymark, Schooling (2008) Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint Induced Language Therapy for Individuals With Stroke - Induced Aphasia. Journal of Speech, Language and Hearing Research Vol 51 1282-1299 .

Cherney, Patterson, Raymer, Frymark,

Schooling (2008)

Evidence-Based Systematic Review: Effects

of Intensity of Treatment and Constraint

Induced Language Therapy for Individuals

With Stroke - Induced Aphasia. Journal of

Speech, Language and Hearing Research Vol

51 1282-1299 .

CIAT Recent Trends Advance Rehabilitation http://www.advancedrecovery.org/currentads.php Steps Forward Florida http://www.stepstherapy.net/index.html Marquette University Arizona State University

Advance Rehabilitation

http://www.advancedrecovery.org/currentads.php

Steps Forward

Florida

http://www.stepstherapy.net/index.html

Marquette University

Arizona State University

CIAT Recent Trends Neuroplasticity and Rehabilitation Research Use Non-use

Neuroplasticity and Rehabilitation Research

Use

Non-use

CIAT Recent Trends Neuroplasticity Meizner, M (2008) Comprehensive review of functional Imaging studies of treatment induced reacquisition of language in chronic aphasia 13 studies (most case studies and only 3 groups (n=10/11/16) Treatment induced changes of activity in both hemispheres.

Meizner, M (2008)

Comprehensive review of functional Imaging studies of treatment induced reacquisition of language in chronic aphasia

13 studies (most case studies and only 3 groups (n=10/11/16)

Treatment induced changes of activity in both hemispheres.

CIAT Recent Trends Neuroplasticity Raymer et al (2008) Neuroplasticy and Neurorehabilitation Research for Speech Language and Swallowing Disorders.

Raymer et al (2008) Neuroplasticy and

Neurorehabilitation Research for Speech

Language and Swallowing Disorders.

Intensive Aphasia Therapy at North Memorial 2002 two pilots (n=12) 2x/year for 2003, 2004 (6 participants) 3x/year 2005 (6-8 participants) 2006 2007 MSHA home study course Realistic clinical management (i.e. staff, space, cost) Payments Outcomes

2002 two pilots (n=12)

2x/year for 2003, 2004 (6 participants)

3x/year 2005 (6-8 participants)

2006

2007 MSHA home study course

Realistic clinical management (i.e. staff, space, cost)

Payments

Outcomes

Intensive Aphasia Therapy at North Memorial Schedule 3 week program 3x/year 3.5 hours of therapy per day (9-12:30) Pre and post evaluations Total 52.5 hours of Tx

Schedule

3 week program

3x/year

3.5 hours of therapy per day (9-12:30)

Pre and post evaluations

Total 52.5 hours of Tx

Intensive Aphasia Therapy at North Memorial 1 hour individual therapy 1 hour therapy at a computer 1 hour of therapy in a small group (2-3 people) 30 minutes “structured social time”

1 hour individual therapy

1 hour therapy at a computer

1 hour of therapy in a small group

(2-3 people)

30 minutes “structured social time”

Intensive Aphasia Therapy at North Memorial Basic Principles applied Constrain/forced use Intense/massed practice Shaping Personal Relevance Therapeutic games Treatment Multimodality

Basic Principles applied

Constrain/forced use

Intense/massed practice

Shaping

Personal Relevance

Therapeutic games

Treatment

Multimodality

Western Aphasia Battery (2002-2009) <Note> ( ) = Sample Size 2. &quot;Severe&quot; = Patient group with Pre-treatment WAB Quotient 0-39 &quot;Moderate' = Patient group with Pre-treatment WAB Quotient 40-74 &quot;Mild&quot; = Patient group with Pre-treatment WAB Quotient 75-100 11% 68.0 62.6 All Pts. (120) 5% 89.9 85.8 Mild (47) 11% 61.9 56.0 Moderate (52) 27% 33.9 27.3 Severe (21) Ave. % Change Average Post-treatment WAB Aphasia Quotient Average Pre-treatment WAB Quotient

<Note>

( ) = Sample Size

2. &quot;Severe&quot; = Patient group with Pre-treatment WAB Quotient 0-39

&quot;Moderate' = Patient group with Pre-treatment WAB Quotient 40-74

&quot;Mild&quot; = Patient group with Pre-treatment WAB Quotient 75-100

(t-Test: Paired Two Sample for Means) Variable 1: Pre-treatment WAB Quotients Variable 2: Post-treatment WAB Quotients Observations: 120 Hypothesized Mean Difference: 0 (no difference) t-Stat = -11.6 Variable 1 mean = 62.6, Variable 2 mean = 68.0 p-value = 0 Hypothesized Mean Difference (zero, no difference) was rejected. The treatment made statistically significant difference in WAB Quotients

Variable 1: Pre-treatment WAB Quotients

Variable 2: Post-treatment WAB Quotients

Observations: 120

Hypothesized Mean Difference: 0 (no difference)

t-Stat = -11.6

Variable 1 mean = 62.6, Variable 2 mean = 68.0

p-value = 0

(% change in WAB AQ by individual Patient)

Repeat participants WAB AQ n=19

Test of Adolescent/Adult Word Finding N=28

Constraint Induced Aphasia Therapy Evidence Based Practice Issues and future trends: At what point in recovery? Does this replace other approaches? Bakheit et al 2007 A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from post stroke aphasia. How intensive? Bhogal

Issues and future trends:

At what point in recovery?

Does this replace other approaches?

Bakheit et al 2007

A prospective, randomized, parallel group,

controlled study of the effect of intensity of speech and language therapy on early recovery from post stroke aphasia.

How intensive?

Bhogal

Constraint Induced Aphasia Therapy Evidence Based Practice Treatment specific? Maher 2006 Szaflirski et al 2008 What do patients think?

Treatment specific?

Maher 2006

Szaflirski et al 2008

What do patients think?

CIAT Future trends Servicing patients much further out in the recovery process Create additional therapeutic opportunities beyond Tx in order to increase intensity Establish regional intense Tx programs Pharmacology

Servicing patients much further out in the recovery process

Create additional therapeutic opportunities beyond Tx in order to increase intensity

Establish regional intense Tx programs

Pharmacology

CIAT Future Trends How can you apply this concept to your clinical work?

How can you apply this concept to your clinical work?