Intensive Aphasia Program


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Intensive Aphasia Treatment Program
The North Memorial Stroke Center is the first in the region to offer this innovative outpatient program that includes many hours of intense therapy over the course of three weeks. The program is designed to help participants relearn old ways or develop new alternative ways of communicating. Patients participate in a combination of individual and group treatments sessions for approximately three and a half hours per day, five days a week.

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Intensive Aphasia Program

  1. 1. 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]
  2. 3. Tissue Plasminogen Activator (t-PA) 1997 <ul><li>Product of recombinant DNA technology </li></ul><ul><li>Activity may last for several hours once bound to a clot </li></ul>
  3. 4. Interventional Stroke Therapy
  4. 5. Intra-Arterial Thrombolysis
  5. 6. Carotid Stents <ul><li>Angiogram </li></ul><ul><li>Percutaneous balloon angioplasty </li></ul><ul><li>Placement of stent in the carotid artery </li></ul>
  6. 7. Stroke Prevalence <ul><li>730,000 strokes per year </li></ul><ul><li>160,000 deaths a year </li></ul><ul><li>Third leading cause of death </li></ul><ul><li>4,000,000 stroke survivors </li></ul><ul><li>Leading cause of adult disability </li></ul>Source: Stroke Facts: NSA 2004
  7. 8. Introduction <ul><li>What do stroke survivors with apashia want? </li></ul><ul><ul><li>1- Meet others with aphasia </li></ul></ul><ul><ul><li>&quot;Speak Easy&quot; </li></ul></ul><ul><ul><li>&quot;Coffee and Conversation&quot; </li></ul></ul>
  8. 9. Introduction <ul><li>2- MORE THERAPY! </li></ul>
  9. 10. Constraint Induced Aphasia Therapy
  10. 11. <ul><li>Write down one way you might implement these concepts into your clinical practice. </li></ul>
  11. 12. Constraint Induced Aphasia Therapy (CIAT) (general outline for our discussion) <ul><li>History and evidence </li></ul><ul><li>Basic Principles </li></ul><ul><li>Trends </li></ul><ul><li>Intense Aphasia Therapy at North Memorial 2002-2009 </li></ul><ul><li>Issues and future trends </li></ul>
  12. 13. CIAT History and Evidence <ul><li>History and evidence </li></ul><ul><ul><li>a. Benefits of therapy in the late/&quot;chronic&quot; stages of recovery </li></ul></ul><ul><ul><li>b. Regular versus Intense therapy </li></ul></ul><ul><ul><li>c. Constraint Induced Aphasia Therapy </li></ul></ul>
  13. 14. CIAT History and Evidence <ul><li>Sheehan (1947, 1948) </li></ul><ul><li>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. </li></ul>
  14. 15. CIAT History and Evidence <ul><li>Schuell 1964 </li></ul><ul><ul><li>Auditory/sensory stimulation affects brain activity </li></ul></ul><ul><ul><li>Repeated stimulation is essential for acquisition, organization, storage and retrieval </li></ul></ul>
  15. 16. CIAT History and Evidence <ul><li>Poeck (1989) </li></ul>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.
  16. 17. CIAT History and Evidence <ul><li>Poeck (cont) </li></ul>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.
  17. 18. CIAT History and Evidence <ul><li>Mackenize (1991) </li></ul><ul><li>Attempting to lend support for tx in </li></ul><ul><li>general, she concluded that researchers </li></ul><ul><li>who did not find tx to be beneficial were </li></ul><ul><li>typically provided fewer than 50 hours…. </li></ul><ul><li>N=5, All had been D/C from Tx (>9mpo). All 4 had </li></ul><ul><li>1 month of no Tx, 4 weeks of Intense Tx (2-3 hours </li></ul><ul><li>per day), and then no treatment. Skills were gained </li></ul><ul><li>and maintained. </li></ul>
  18. 19. CIAT History and Evidence <ul><li>Conclusion: </li></ul><ul><li>Gains were made in one month that one might otherwise make if Tx were spread out over one year. </li></ul>
  19. 20. CIAT History and Evidence <ul><li>Robey, R. R. (1994). The efficacy of treatment for aphasic persons: A meta-analysis. Brain and Language, 47, 582-608. </li></ul><ul><li>Meta Analysis of aphasia literature revealed large effect sizes with Tx provided for 2 or more hours per week. </li></ul>
  20. 21. CIAT History and Evidence <ul><li>Denes, Perazzolo, Piani & Piccione (1996) </li></ul><ul><li>Compared intensive therapy (daily) versus regular (3x/week) in a group of patients with global aphasia . </li></ul><ul><li>Following therapy, both groups showed significant improvement in language. Those receiving intensive therapy showed the more favorable outcome. </li></ul>
  21. 22. CIAT History and Evidence <ul><li>Hinckley, Craig (1998) </li></ul><ul><li>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. </li></ul>
  22. 23. CIAT History and Evidence <ul><li>Dr. Edward Taub </li></ul><ul><li>University of Alabama, Birmingham </li></ul><ul><li>Taub, E. Crago, J. E. Uswatte, G (1998). Constraint-Induced Movement </li></ul><ul><li>Therapy: A New Approach to Treatment in Physical Rehabilitation. VOL </li></ul><ul><li>43; NUMBER 2, pages 152-170. </li></ul><ul><li> </li></ul>
  23. 24. CIAT History and Evidence <ul><li>Dr. Edward Taub (1998) </li></ul><ul><li>Cortical mapping </li></ul><ul><li>Learned non-use </li></ul><ul><li>Motor behavior is modifiable – &quot;Use it to improve it&quot; </li></ul><ul><li>Constraints </li></ul><ul><li>Massed practice </li></ul><ul><li>120 published studies including a single-site, placebo-controlled trial (Taub, 2006) and a large multisite randomized trial (Wolf, 2006). </li></ul>
  24. 25. CIAT History and Evidence <ul><li>Pradat-Diehl, Tessier (2001) </li></ul><ul><li>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. </li></ul>
  25. 26. CIAT History and Evidence <ul><li>Pulvermuller et al 2001 </li></ul><ul><li>&quot;Constraint Induced Aphasia Therapy“ </li></ul><ul><li>Basic Principles </li></ul><ul><li>Constrain/forced use </li></ul><ul><li>Concentrated Massed-Practice </li></ul><ul><li>Shaping </li></ul><ul><li>Relevance </li></ul><ul><li>Therapeutic games </li></ul>
  26. 27. CIAT History and Evidence <ul><li>Methods: </li></ul><ul><li>17 patients with chronic aphasia </li></ul><ul><li>Randomly assigned to conventional therapy (CT) or CIAT </li></ul><ul><li>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 </li></ul><ul><li>group. </li></ul>
  27. 28. CIAT History and Evidence <ul><li>CIAT = 3-4 hours per day x10days (avg of 31.5 total hours) </li></ul><ul><li>CT = 1 hour per day for 3-5 weeks (avg of 33.9 total hours) </li></ul>
  28. 29. CIAT History and Evidence <ul><li>CIAT: </li></ul><ul><li>Materials </li></ul><ul><li>32 cards with 16 pictures (common name or high </li></ul><ul><li>frequency word or tailored to individual needs i.e. </li></ul><ul><li>minimal pairs sock/rock, white/black) </li></ul><ul><li>Hierarchy for requests/constrain </li></ul><ul><li>Name </li></ul><ul><li>Article or designated object </li></ul><ul><li>Syntactically correct sentence </li></ul><ul><li>Reinforcement per expectation of the patient- be clear on what is expected </li></ul>
  29. 30. CIAT History and Evidence <ul><li>CT: </li></ul><ul><li>Syndrome specific methods considered </li></ul><ul><li>standard in Germany including interventions </li></ul><ul><li>such as naming, repetition, sentence </li></ul><ul><li>completion, following instructions, </li></ul><ul><li>conversations on topics of the patient's choice, </li></ul><ul><li>training of various communicative methods. </li></ul>
  30. 31. CIAT History and Evidence <ul><li>Outcomes </li></ul><ul><li>Aachen Aphasia Battery </li></ul><ul><li>Significant improvement for CI group (17%) </li></ul><ul><li>No significant improvement for CT (2%) </li></ul><ul><li>Communication in everyday life: </li></ul><ul><li>30% increase for CI </li></ul><ul><li>0% reported for CT </li></ul>
  31. 32. CIAT History and Evidence <ul><li>Agree that plateau exists within first year post stroke. </li></ul><ul><li>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. </li></ul>
  32. 33. CIAT History and Evidence <ul><li>Future research should investigate: </li></ul><ul><ul><li>Whether even more intense Tx can further improve outcome </li></ul></ul><ul><ul><li>Whether outcomes are maintained for long periods </li></ul></ul><ul><ul><li>Whether outcomes differ between patient profiles i.e. aphasia types, psychiatric issues an in what ways the components of CI contribute to the outcome. </li></ul></ul>
  33. 34. CIAT History and Evidence <ul><li>Bhogal, Teassell, Speechley, Albert (2003) </li></ul><ul><li>Intensity of Aphasia Therapy, Impact on Recovery- Aphasia therapy works </li></ul><ul><li>“ 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.” </li></ul><ul><li>“ 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” </li></ul>
  34. 35. CIAT History and Evidence <ul><li>Meizner 2005 </li></ul><ul><li>Examined the efficacy of a short-term, intensive language training, constraint-induced aphasia therapy (CIAT) and CIAT-Plus. </li></ul>
  35. 36. CIAT History and Evidence <ul><li>Maher (2006) </li></ul><ul><li>Intense therapy for verbal versus non-verbal interventions. </li></ul>
  36. 37. CIAT History and Evidence <ul><li>Cherney, Patterson, Raymer, Frymark, </li></ul><ul><li>Schooling (2008) </li></ul><ul><li>Evidence-Based Systematic Review: Effects </li></ul><ul><li>of Intensity of Treatment and Constraint </li></ul><ul><li>Induced Language Therapy for Individuals </li></ul><ul><li>With Stroke - Induced Aphasia. Journal of </li></ul><ul><li>Speech, Language and Hearing Research Vol </li></ul><ul><li>51 1282-1299 . </li></ul>
  37. 38. CIAT Recent Trends <ul><li>Advance Rehabilitation </li></ul><ul><li> </li></ul><ul><li>Steps Forward </li></ul><ul><li>Florida </li></ul><ul><li> </li></ul><ul><li>Marquette University </li></ul><ul><li>Arizona State University </li></ul>
  38. 39. CIAT Recent Trends <ul><li>Neuroplasticity and Rehabilitation Research </li></ul><ul><li>Use </li></ul><ul><li>Non-use </li></ul>
  39. 40. CIAT Recent Trends Neuroplasticity <ul><li>Meizner, M (2008) </li></ul><ul><li>Comprehensive review of functional Imaging studies of treatment induced reacquisition of language in chronic aphasia </li></ul><ul><li>13 studies (most case studies and only 3 groups (n=10/11/16) </li></ul><ul><li>Treatment induced changes of activity in both hemispheres. </li></ul>
  40. 41. CIAT Recent Trends Neuroplasticity <ul><li>Raymer et al (2008) Neuroplasticy and </li></ul><ul><li>Neurorehabilitation Research for Speech </li></ul><ul><li>Language and Swallowing Disorders. </li></ul>
  41. 42. Intensive Aphasia Therapy at North Memorial <ul><li>2002 two pilots (n=12) </li></ul><ul><li>2x/year for 2003, 2004 (6 participants) </li></ul><ul><li>3x/year 2005 (6-8 participants) </li></ul><ul><li>2006 </li></ul><ul><li>2007 MSHA home study course </li></ul><ul><li>Realistic clinical management (i.e. staff, space, cost) </li></ul><ul><li>Payments </li></ul><ul><li>Outcomes </li></ul>
  42. 43. Intensive Aphasia Therapy at North Memorial <ul><li>Schedule </li></ul><ul><ul><li>3 week program </li></ul></ul><ul><ul><li>3x/year </li></ul></ul><ul><ul><li>3.5 hours of therapy per day (9-12:30) </li></ul></ul><ul><ul><li>Pre and post evaluations </li></ul></ul><ul><ul><li>Total 52.5 hours of Tx </li></ul></ul>
  43. 44. Intensive Aphasia Therapy at North Memorial <ul><li>1 hour individual therapy </li></ul><ul><li>1 hour therapy at a computer </li></ul><ul><li>1 hour of therapy in a small group </li></ul><ul><ul><li>(2-3 people) </li></ul></ul><ul><ul><li>30 minutes “structured social time” </li></ul></ul>
  44. 45. Intensive Aphasia Therapy at North Memorial <ul><li>Basic Principles applied </li></ul><ul><ul><li>Constrain/forced use </li></ul></ul><ul><ul><li>Intense/massed practice </li></ul></ul><ul><ul><li>Shaping </li></ul></ul><ul><ul><li>Personal Relevance </li></ul></ul><ul><ul><li>Therapeutic games </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Multimodality </li></ul></ul>
  45. 48. Western Aphasia Battery (2002-2009) <ul><li><Note> </li></ul><ul><li>( ) = Sample Size </li></ul><ul><li>2. &quot;Severe&quot; = Patient group with Pre-treatment WAB Quotient 0-39 </li></ul><ul><li>&quot;Moderate' = Patient group with Pre-treatment WAB Quotient 40-74 </li></ul><ul><li>&quot;Mild&quot; = Patient group with Pre-treatment WAB Quotient 75-100 </li></ul>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  
  46. 49. (t-Test: Paired Two Sample for Means) <ul><li>Variable 1: Pre-treatment WAB Quotients </li></ul><ul><li>Variable 2: Post-treatment WAB Quotients </li></ul><ul><li>Observations: 120 </li></ul><ul><li>Hypothesized Mean Difference: 0 (no difference) </li></ul><ul><li>t-Stat = -11.6 </li></ul><ul><li>Variable 1 mean = 62.6, Variable 2 mean = 68.0 </li></ul><ul><li>p-value = 0 </li></ul>Hypothesized Mean Difference (zero, no difference) was rejected. The treatment made statistically significant difference in WAB Quotients
  47. 50. (% change in WAB AQ by individual Patient)
  48. 51. Repeat participants WAB AQ n=19
  49. 52. Test of Adolescent/Adult Word Finding N=28
  50. 53. Constraint Induced Aphasia Therapy Evidence Based Practice <ul><li>Issues and future trends: </li></ul><ul><ul><li>At what point in recovery? </li></ul></ul><ul><ul><li>Does this replace other approaches? </li></ul></ul><ul><ul><ul><ul><li>Bakheit et al 2007 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>A prospective, randomized, parallel group, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>controlled study of the effect of intensity of speech and language therapy on early recovery from post stroke aphasia. </li></ul></ul></ul></ul><ul><ul><li>How intensive? </li></ul></ul><ul><ul><ul><li>Bhogal </li></ul></ul></ul>
  51. 54. Constraint Induced Aphasia Therapy Evidence Based Practice <ul><ul><li>Treatment specific? </li></ul></ul><ul><ul><ul><li>Maher 2006 </li></ul></ul></ul><ul><ul><ul><li>Szaflirski et al 2008 </li></ul></ul></ul><ul><ul><li>What do patients think? </li></ul></ul>
  52. 55. CIAT Future trends <ul><li>Servicing patients much further out in the recovery process </li></ul><ul><li>Create additional therapeutic opportunities beyond Tx in order to increase intensity </li></ul><ul><li>Establish regional intense Tx programs </li></ul><ul><li>Pharmacology </li></ul>
  53. 56. CIAT Future Trends <ul><li>How can you apply this concept to your clinical work? </li></ul>