2010 Adult Language Group NSW Speech Pathology Evidence Based Practice NETWORK

1. 2010Adult Language Group NSW Speech Pathology Evidence Based Practice NETWORK  Janine Mullay and Claire Layfield (Group Co-Leaders) Lyndsey Nickels - Academic Member

2. CLINICAL QUESTION 2010 Does Constraint Induced Therapy Improve Communication Outcomes in People with Aphasia?

3. Constraint induced language therapy (CILT) Originated from CI movement therapy used by Physios and Occupational Therapists Removes compensatory strategies Requires the use of verbal output Intensive over short period of time Conducted within small group settings The idea behind constraint induced movement therapy is to force the use of the affected side by restraining the unaffected side. So this client would have their left arm constrained thus forcing the use of their right arm. The third element of this therapy technique is to have the client do it intensively. The principles of constraint-induced (CI) therapy are now also being used to treat aphasia. But what does this look like? It looks like taking away the compensatory strategies that we teach people with aphasia and forcing them to use their speech. The idea behind it is that we are so good at teaching them compensatory strategies that they have learned non-use of their speech. Constraint induced aphasia therapy forces the patient to communicate verbally without using gestures, drawing or writing. Therapy is intensive over short periods of time. The idea behind constraint induced movement therapy is to force the use of the affected side by restraining the unaffected side. So this client would have their left arm constrained thus forcing the use of their right arm. The third element of this therapy technique is to have the client do it intensively. The principles of constraint-induced (CI) therapy are now also being used to treat aphasia. But what does this look like? It looks like taking away the compensatory strategies that we teach people with aphasia and forcing them to use their speech. The idea behind it is that we are so good at teaching them compensatory strategies that they have learned non-use of their speech. Constraint induced aphasia therapy forces the patient to communicate verbally without using gestures, drawing or writing. Therapy is intensive over short periods of time.

4. BACKGROUND TO CLINICAL QUESTION Effectiveness of CILT was reviewed in 2006 EBP Language group Topic has generated more research and discussion since 2006 Results from 2006 EBP review were inconclusive Aim of 2010 EBP group was to (i) evaluate new evidence (ii) provide a resource for EBP website for SP access

5. 2010 CAPS Selection criteria = treatment effects of CILT, aphasia post stroke and chronic aphasia (> 6 months post stroke) 12 possible articles were found 10 out of 12 answered our clinical question and were included in the CAT

6. Results Indicate… Overall results indicate that CILT leads to improved language outcomes 9/10 studies reported significantly improved language outcomes on standardised measures 1/10 demonstrated a trend indicating improved outcomes without statistical significance On analysis of the results from the articles there is an overwhelming trend indicating that CILT leads to significantly improved language outcomes. On analysis of the results from the articles there is an overwhelming trend indicating that CILT leads to significantly improved language outcomes.

7. Results Indicate Although results typically indicated that CILT lead to improved language outcomes only a few studies investigated generalised language outcomes Modified versions targeting generalisation and agrammatism Despite this overwhelming trend there were also some limitations which we noted as a group as part of the CAPPING process Despite this overwhelming trend there were also some limitations which we noted as a group as part of the CAPPING process

8. Results Indicate What is the mechanism behind the improvements??? Constraint vs intensive other treatments

9. Results Indicate

10. The Evidence… Cherney, LR, Patterson,JP, RAymer, A, Frymark,T, Schooling, T. (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.51(5):1282-1299. CLINICAL BOTTOM LINE: Although moderate evidence exists for more intensive treatment and CILT for individuals with stroke induced aphasia, the results of this systematic review should be interpreted conservatively and used in conjunction with clinical expertise and clients’ values.

11. The Evidence… Pulvermuller, F; Neininger, B; Elbert, T; Mohr, B; Rockstroh, B; Koebbel, P; Taub, E (2001) Constraint-induced therapy of chronic aphasia after stroke. In Stroke, Vol 32; pp. 1621-1626. CLINICAL BOTTOM LINE: Massed-practice constraint induced therapy performed intensely over a short period of time with patients with chronic aphasia resulted in improved performance on standardised assessment/questionnaire. In comparing with “conventional” therapy, it is difficult to conclude whether constraint induced therapy was more effective as the treatments were not administered in the same frequency.

12. The Evidence… Meinzer M. Djundja D. Barthel G. Elbert T. Rockstroh B. Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke. 36(7):1464-6, 2005 Jul. CLINICAL BOTTOM LINE: Massed-practice constraint-induced therapy performed intensely over a short period of time with patients with chronic aphasia resulted in improved performance on standardised assessment and questionnaires regarding quantity/quality of communication. Unable to assess effectiveness from other more conventional therapies

13. The Evidence… Faroqi-Shah Y, Virion CR (2009) Constraint-induced language therapy for aggrammaticality constraints. Aphasiology. 23 (7-8); 977-88. CLINICAL BOTTOM LINE: Constraint induced language therapy (with or without grammatical shaping) may lead to improved performance in therapy tasks for patients with Broca’s Aphasia, but may not lead to improvement in overall language severity measures or in conversational & narrative speech samples.

14. The Evidence… Maher, L., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S., Pingel, K., Holland, A., & Gonsalez Rothi, L. (2006). A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12 (1), 843-852. CLINICAL BOTTOM LINE: Constraint induced language therapy can improve communication outcomes based on measures of the WAB (Aphasia Quotient), Boston Naming Test, Action Naming Test and narrative discourse, in people with Aphasia. However, there were nil significant differences between CILT and PACE therapy.

15. The Evidence… Meinzer, M., Streiftau, S., & Rockstroh, B. (2007). Intensive language training in the rehabilitation of chronic aphasia: Efficient training by laypersons. Journal of the International Neuropsychological Society, 13(5), 846-853. CLINICAL BOTTOM LINE: CIAT resulted in positive language outcomes for all individuals with chronic aphasia and can be administered by trained laypersons with results comparable to that of experienced therapists.

16. The Evidence… Virion, C. R. (2008). “Go aphasia!”: Examining the efficacy of constraint-induced language therapy for individuals with agrammatic aphasia (Master’s Thesis). Available from Digital Repository at the University of Maryland. (Identifier No. 8611). CLINICAL BOTTOM LINE: Constraint induced therapy may not improve language outcomes for people with agrammatic aphasia. Modifying constraint induced therapy in its original form to include a grammatical constraint may increase its efficacy in this population.

17. The Evidence… Goral M & Kempler D (2009). Training verb production in communicative context: Evidence from a person with chronic non-fluent aphasia. Aphasiology, 23 (12), 1383-1397. CLINICAL BOTTOM LINE: Constraint Induced Language Therapy for the verbal production of verbs is successful in a person with chronic non-fluent aphasia, and improves perceptions of one’s communicative competence overall.

18. The Evidence… Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM, Neils-Strunjas J, Newmeyer A, Reichhardt R. (2008) Constraint Induced Aphasia Therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Medical Science Monitor, 14 (5) 243 – 250. CLINICAL BOTTOM LINE: A customised, intensive (1 week), structured Constraint Induced Aphasia Therapy approach may improve listening skills and story retell ability

19. The Evidence… Breier, J.I. Juranek, L. M. Maher, S. Schmadeke, D. Men, A. C. Papanicololaou (2009). Behavioural and Neurophysiologic Response to Therapy for Chronic Aphasia. Arch Phys Med Rehabilitation. 90:2026-33. CLINICAL BOTTOM LINE: Although the Right hemisphere may support recovery of language function in response to CILT, this recovery may not be stable and some participation of perilesional areas of the left hemisphere may be necessary for a stable behaviour response

20. Applying the results to clinical practice Amanda Osbourne presented results from the CILT group she ran in 2010 at the Aphasiology Symposium Clients were recruited from two different metropolitan outpatient speech pathology services – one group was conducted at each site Clients were referred to the group as they had ongoing aphasia of varying degrees however had plateaued in traditional naming therapy. They had all had inpatient rehabilitation and at least one block of traditional outpatient therapy.

21. Applying the results to clinical practice – CILT Group A Group A ran for 1 ½ hours twice a week for 4 weeks. Total of 12 hours of therapy 2 participants Go-fish game 16x2 picture cards (2 sets of these) Barriers were used Clients had to explicitly address one of the players Pointing, gesturing, writing and drawing was not permitted – these were the constraints Clients had to name the pictures (normally about 40 attempts each session) As the client improved they had to attempt to use sentences to ask for the pictures She took 16 cards of basic objects or actions and made a double set of these. After a few sessions these were getting repetitive so she developed another 16 cards of basic words or actions. She used barriers between clients and the aim of the game was to ask other players for the card in your hand in order to form a pair. Go Fish! At the start some of the clients could only say the single word – or in fact couldn’t even say that! As therapy progressed and dependant on their level they would try and put the word into a sentence. For example… George, do you have the picture of the man and woman doing the gardening. Throughout this whole process clients were not allowed to use pointing, or show the card they wanted or gesture or write or draw. They had to try and say it. The client that was asked would then have to repeat the sentence or words and say. No I don’t have the picture of the man and woman doing the gardening. In any given session clients got to say the target words about 40 times all together. She took 16 cards of basic objects or actions and made a double set of these. After a few sessions these were getting repetitive so she developed another 16 cards of basic words or actions. She used barriers between clients and the aim of the game was to ask other players for the card in your hand in order to form a pair. Go Fish! At the start some of the clients could only say the single word – or in fact couldn’t even say that! As therapy progressed and dependant on their level they would try and put the word into a sentence. For example… George, do you have the picture of the man and woman doing the gardening. Throughout this whole process clients were not allowed to use pointing, or show the card they wanted or gesture or write or draw. They had to try and say it. The client that was asked would then have to repeat the sentence or words and say. No I don’t have the picture of the man and woman doing the gardening. In any given session clients got to say the target words about 40 times all together.

22. Results Unfortunately we can’t go through all of the results in detail but briefly……… Unfortunately we can’t go through all of the results in detail but briefly………

23. Results Some reasons for this: Not same intensity as CILT standard application Little interaction with family – not much home practice and generalisation (lack of generalisation consistent with CILT results) CETI is self or family rating scale – so results may be more indicative of increased awareness rather than reduced performance. Better understanding of tool by end and therefore used more appropriatelySome reasons for this: Not same intensity as CILT standard application Little interaction with family – not much home practice and generalisation (lack of generalisation consistent with CILT results) CETI is self or family rating scale – so results may be more indicative of increased awareness rather than reduced performance. Better understanding of tool by end and therefore used more appropriately

24. Results

25. Structure of CILT Group B Group ran for 1 ½ hours twice a week for 4 weeks (intensive) Total of 12 hours 3 participants Go-fish game – 16x2 picture cards (3 sets of these) used barriers clients had to explicitly address one of the players pointing, gesturing, writing and drawing was not permitted had to name the pictures (normally about 30-40 attempts each session) Had to put the words into whole sentences as they improved CIAT plus – additional exercises performed each day using constraints in everyday conversation e.g. buy bread or go to travel agent. They had to rate their speech during this Meinzer et al 2005 used this CIAT plus idea.Meinzer et al 2005 used this CIAT plus idea.

26. Results All participants improved in their CETI and modified CETI pre and post scores indicating improved functional communication. Even though this was a small sample size and not a rigorous research design, it still suggests that communication practice within context is important for generalisation of language gains.All participants improved in their CETI and modified CETI pre and post scores indicating improved functional communication. Even though this was a small sample size and not a rigorous research design, it still suggests that communication practice within context is important for generalisation of language gains.

27. Results One participant improved in the frequency of communication and the other remained consistent pre and post. However, this is not an indication of successful communication interactions.One participant improved in the frequency of communication and the other remained consistent pre and post. However, this is not an indication of successful communication interactions.

28. Results As we can see from both the research and the application to clinical practise, there seems to be some worthwhile benefits of this therapy approach and its definitely worth considering with certain client populations, especially if clients have plateaued with the current approach or are referred for a block of intensive therapy many years post their stroke (taking neuroplasticity evidence into consideration too). As we can see from both the research and the application to clinical practise, there seems to be some worthwhile benefits of this therapy approach and its definitely worth considering with certain client populations, especially if clients have plateaued with the current approach or are referred for a block of intensive therapy many years post their stroke (taking neuroplasticity evidence into consideration too).

29. REFERENCES Barthel, G., Meinzer, M., Djundja, D., Rockstroh, B. (2007). Intensive language therapy in chronic aphasia: Which aspects contribute the most? Aphasiology, 22 (4), 408-421. Breier, J.I., Juranek, J., Maher, L.M., Schmadeke, S., Men, D., Papanicolaou, A.C. (2009). Behavioural and Neurophysiologic Response to Therapy for Chronic Aphasia. Arch Phys Med Rehabilitation. 90: 2026-33. Cherney LR, Patterson JP, Raymer A, Frymark T, Schooling T. (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 51 (5) :1282-1299. Faroqi-Shah Y, Virion CR (2009) Constraint-induced language therapy for aggrammaticality constraints. Aphasiology. 23 (7-8); 977-88. Goral M, Kempler D (2009) Training verb production in communicative context: evidence from a person with chronic non-fluent aphasia. Aphasiology. 23 (12) 1383-97. Maher LM, Kendall D, Swearengin JA, Rodriguez A, Leon SA, Pingel K, Holland A, Rothi LJ. (2006) A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12 (6): 843-52.

30. REFERENCES Meinzer M, Djundja D, Barthel G, Elbert T, Rockstroh B. (2005) Long-term stability of improved language functions in chronic aphasia after Constraint-Induced Aphasia Therapy. Stroke, 36: 1462-1466. Meinzer, M., Streiftau, S., Rockstroh, B. (2007). Intensive language training in the rehabilitation of chronic aphasia: Efficient training by laypersons. Journal of the International Neuropsychological Society, 13 (5), 1355-6177. Pulvermuller R, Neininger B, Elbert T, Mohr B, Rockstroh B, Koebbel P, Taub E. (2001) Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7): 1621-6. Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM, Neils-Strunjas J, NewmeyerA, Reichhardt R. (2008) Constraint-induced aphasia therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Medical Science Monitor, 14 (5) 243 – 250. Virion, C.R. (2008). “Go Aphasia”: Examining the efficacy of constraint induced language therapy for individuals with agrammatic aphasia. –Thesis

31. Questions……..