An Interdisciplinary, Intensive Treatment Program for Persons

With Aphasia Elizabeth Hoover

Gloria Waters Anne Carney David Caplan

Disclosures

• Elizabeth Hoover: I work for Boston University. I have no other relevant financial or nonfinancial relationships to disclose. This research was approved by the Institutional Review Board at BU; I served as the PI.

• Anne Carney: I work for Boston University. I have no other relevant financial or nonfinancial relationships to disclose.

• Founded in 2006 at Sargent College of Health and Rehabilitation Sciences

• Aphasia Community Support Group

• Provides weekly treatment groups for pwa based on Life Participation Approach to Aphasia

• www.bu.edu/aphasiacenter/

Overview of Presentation

• Background and Introduction

• 2011 Pilot Program

• 2012 Program (within subjects, multiple-baseline) • Description/examples of treatment

• Review and discussion of results

• Discussion of the direction of future work

Background

• Request from a client from the Aphasia Resource Center at Boston University.

• Donation of funds to execute program.

Living with Aphasia: Framework for Outcome Measurement (A-FROM)

Reprinted with permission from the Aphasia Institute, Toronto, Canada.

(Kagan et al, 2008)

Continuum of Naturalness

Martin, N, Thompson, C, and Worral, L (2007)

Treatment

• Individual Treatment: • Many treatments have been shown to improve discrete

language functions (Robey et al, 1998), but those newly learned skills do not always transfer readily to non-trained environments.

• Group Treatment: • Social approaches to aphasia assessment and treatment

offer a natural and dynamic vehicle to improve social communication (Elman, 2007).

• Group treatment, a respected social approach, has been shown to improve discrete language skills in persons with aphasia (Elman & Bernstein-Ellis, 1999)

?

Treatment Intensity

• Research in treatment of aphasia has shown that “intensity” of treatment is an important factor in recovery (Basso, 2005).

• Bhogal et al (2003) found that treatment provided on a more intense level (8.8 hours/week) for a shorter period of time resulted in stronger improvements compared to treatment provided on a less intense level over a long period of time.

Intensive Aphasia Tx Programs in North America

• InteRACT (Dalhousie University, Halifax, Nova Scotia)

• University of Michigan Aphasia Program (UMAP)

• Rehabilitation Institute of Chicago (RIC)

• Program for Intensive Residential Aphasia Treatment and Education (PIRATE; at Pittsburgh Veterans Affairs Hospital)

• These programs focus exclusively on either speech-language or speech-language and recreational therapy.

And yet……

• Individuals with aphasia often have • Motor and sensory issues

• Cognitive issues

• Visual issues

• Cardiac, cholesterol and/or weight issues

• Resulting in reduced participation in daily activities

Resulting in …..

• Need for interdisciplinary services including: • Nutritional Counseling

• Occupational Therapy

• Physical Therapy

• Speech-language Therapy

Pilot Program

• Interdisciplinary.

• Intensive (i.e. >20 hours/week).

• Incorporates both individual SLP treatment and group treatment delivery for all disciplines.

• Addresses client-centered goals focused in meaningful and relevant domains using evidence-based treatment approaches.

• Explicit training of goals across contexts, individual to group to other disciplines to community.

Components

• Recruited 6 participants s/p language-hemisphere dominant stroke with a mild-moderate profile of aphasia and a need for interdisciplinary treatment.

• Each participant agreed to: • complete ~ 5 hours of pre- and post- testing • participate in 6 hours of interdisciplinary treatment 5 days/week for four weeks:

• Nutrition: one hour daily group treatment (which included lunch) • OT: one hour group treatment 4-5 days/week • PT: 90 minutes group treatment 3 days/week • SLP:

• 3 hours individual treatment/week

• 3 hours dyadic treatment/week

• 10.5 hours group treatment/week

• OT and SLP incorporated student involvement. • Neuro-residency fellowship for PT. • All participants were given iPads to use during, then keep after the program.

Patient Goal: Independence in Dining Out

PT: Gait Balance & Endurance Training

Practiced Community Ambulation and Use

of Public Transportation

Speech:

Tx for vocabulary: SFA, PCA, CILT,

Script Training, Community Outing to

Restaurant.

Nutrition:

Modify diet to meet nutritional needs and healthy weight with

increased activity

Review Menu of Restaurant online

using iPad

OT: Accessing public transportation and

identifying restaurants in neighborhood

Team Approach towards a

Community Goal.

SLP Program

• Individual goals targeted over three treatment types: • Individual • Dyadic • Group

• 16.5 hours of SLP provided each week.

Verbal Language Outcomes

• Philadelphia Naming Test (PNT) (Roach et al, 1996) • Verb Naming Test (VNT) (Thompson, 2002) • Psycholinguistic Assessment of Language (PAL) (Caplan & Bub,

1990): • Homophone Judgment • Oral Repetition • Production of Affixed Words • Sentence Production

• Discourse Comprehension Test (DCT) (Brookshire & Nicholas, 1997)

• Picture Description (Nicholas and Brookshire, 1994) • Assessment of living with Aphasia (ALA) (Kagan et al, 2010) • Stroke Impact Scale (SIS) (Duncan et al, 2002)

Pre - post treatment results on specific speech-language measures

Standard Deviations of change per client compared to published, control group normative data

Post Hoc Analysis of ‘Targeted’ Measures

• Accuracy scores were calculated for the speech-language measures in targeted areas of treatment each client.

• Results revealed statistically significant changes pre and post treatment (Z=-3.020, df=31, p=0.003).

Mean group scores on target measures in SLP pre and post treatment

54.00

56.00

58.00

60.00

62.00

64.00

66.00

68.00

70.00

72.00

74.00

PRETEST POST-TEST

Z=-3.020, df=31, p=0.003)

Outcomes for PT, OT and Nutrition

• PT: • Statistically significant improvements in Speed and Endurance

• (6 min Walk Test p=.01, Ten Meter Walk Test p=.01 ).

• Statistically improved Balance • (Dynamic Gait Index p=.001 , Mini Best p=.02 ).

• OT: • Statistically significantly Improved use of affected upper extremity

• (COPM performance p=.003, satisfaction p=.341) • (Motor Activity Log: how often p=.006, how well p=.022 )

• Nutrition: • Statistically significant changes in Weight Loss p=.006 and Body Mass Index

p=.02.

• (graphs in “appendix” at end of handout.)

Sample Family Member Testimonials

• Increased communication skills: • Spoke more fluently, • Got stuck less often • Spoke more often • Had more to talk about • Initiated more conversation

• Increased confidence (talked to new people)

• Increased sense of normalcy “like going to work”

• Improved diet

• Went on walks with spouse

Take Two

• Intensive, Interdisciplinary Treatment Study for PWA: • Multiple Baseline Study

• 4 repeated measures across same discrete language tasks • ALA –> ASHA FACS (pre and post) • Stroke Impact Scale (pre and post)

• Increased number of participants • Increased variability in profile of aphasia • Schedule/treatment modifications

Subject Selection Criteria

• Present with a mild or moderate profile of aphasia secondary to a single stroke, as diagnosed by a certified speech-language pathologist.

• Demonstrate mobility or sensory deficits as a result of the stroke.

• Demonstrate cardiac/nutritional needs.

• Be able to ambulate without the physical assistance of another person for at least 500 feet.

Participant Profiles

• 1 moderate-severe Fluent (**Evolving Wernicke’s)

• 1 moderate-severe non-fluent (Broca’s)

• 1 moderate non-fluent(Broca’s)

• 4 mild-moderate fluent (Conduction profile)

• 1 mild fluent (Anomic)

• Time Post-Onset: 16 months to 12 years.

2012 Program

• Review Treatment Schedule • Modifications from 2011

• Discuss SLP Program in detail • Individual, Group and Dyadic Treatment

• Highlight Interdisciplinary Elements

• Provide Examples of Carryover into Community

Timing of Baselines

• One month pre-treatment

• Immediately pre-treatment

• Immediately post-treatment

• Three months post-treatment

Same verbal language measures as pilot

Plus SIS, ASHA-FACS

2012 Schedule

The Schedule

“It was hard…The program was very difficult…We were tired…”

Treatment Modifications from 2011

• iPads were again provided for duration of program and to keep

• Separated individual therapy into 3 one-hour increments across 3 days

• Addition of debate/news group

• Additional hour of CILT/dyadic tx

• More consistent use of SKYPE/conversation in computer group.

SLP Program

• Individual goals targeted over three treatment types: • Individual – 3 hours/week • Dyadic – 3.5 hours/week • Group – 9.5 hours/week

• 16 hours of SLP provided each week.

Individualized SLP Treatment: (3 x 60 min/week)

Group Treatment: 9.5 hrs/week Nuts & Bolts

Computer (iPad/Skype): 2 hrs/week

Toastmasters: 1 hr/week

Book Club: 1 hr/week

Newsletter: 1 hr/week

Games: 1 hr/week

Debate/News: 1 hr/week

Conversation/Current Issues/Wrap-Up: 2.5 hrs/week

Group Treatment: Computer (iPad/Skype)

• Free or low-cost apps to support communication and life participation (e.g. Calendar, Contacts, Maps, Notes, Photos, FaceTime/Skype, Dragon, The Weather Channel)

• Apps designed specifically to support speech and language (e.g. Tactus Therapy suite, VAST, Language Builder)

• Individualized apps (e.g. Pictello and Proloquo2go) to support AAC needs

• Accessibility features (e.g. Reader and Speak Selection)

• Skype video calls with other aphasia centers (e.g. Adler Aphasia Center, Stroke Comeback Center) and with “Mystery Guests” with connections to aphasia (e.g. Audrey Holland, Paul Berger). • Mystery Guest format inspired by the Adler Aphasia Center’s Skype

Group

Group Treatment: Sample iPad Instructions

Book Club

• How to Conquer the World with One Hand… and an Attitude by Paul Berger

• Read via Kindle app on iPad;

• Audio via Music/iTunes app

• Skype call with Paul Berger

• Chapter Summaries: • The Book ConnectionTM (Bernstein-Ellis & Elman)

Group Treatment: Skype with Paul Berger

“I’m very inspired by your story…. It gives us a lot of spirit to keep on going.” – Participant from 2012 Intensive to Paul Berger during Skype video call.

Book Club: 2011 Intensive Alum

• Participant S – Avid reader pre-stroke

Toastmasters

• Various iPad apps used to support Toastmasters speeches:

Notes Pictello Video Recorder Dragon

• 1:1 support provided during Individual Treatment as needed

Toastmasters: Video Clip Pictello Support

Toastmasters speech requiring maximum clinician support

Toastmasters speech requiring no clinician support using Pictello app

2012 Intensive Reunion: Pictello Presentation

Debate/News Group

Debate/News

Conversation/Current Issues/Wrap-up

• Monday morning conversation group • Discussed weekend

• Provided overview of week ahead

• Current Issues/Wrap-up • Conducted daily check-in

• Generated new stimulus items for dyadic treatment

• Distributed homework

Homework

Dyadic Treatment: 3.5 hours/week

- Inspired by the Constraint Induced Language Treatment (CILT) work of Pulvermüller (2001) and Cherney, Patterson et al’s (2008) evidence-based systematic review of CILT

- Functional, individualized stimulus targets (e.g. occupations, hobbies, geographical locations of personal significance, numbers)

- Pairings were made based on similar goals and/or shared stimulus targets; barriers modified to allow for gesture, facial expression, etc.

- Two components to each session: 1) SFA/PACE with semantic features support sheet 2) Modified CILT – interrogative individualized to carry over goals

from individual therapy (i.e. addition of adjective modifiers, prepositional phrases, clauses, etc.)

Modified SFA/CILT Stimulus Categories

20-25 targets drawn from categories of functional and personal relevance:

• Program Participants, Therapists, Students

• Occupations

• Food/Drink

• Hobbies

• Geographical areas of interest

• Numbers

Dyadic Stimulus Sample: Occupations

SFA Support Sheet Sample

Dyadic Treatment

• Stimulus targets: numbers per client request • Barrier: reduced to allow for nonverbal modalities

Interdisciplinary

• Nutrition: Daily Lunch

• OT/Nutrition: Cooking (Mondays)

• PT: Weekly visits to gym

• All disciplines: iPad usage, community outings

• Weekly Rounds with Interdisciplinary Treatment Team • Transfer of goals across contexts • Aware of transfer/balance issues • Use/support of non-dominant hand • Increased calorie intake to support additional physical activity

Transfer of goals to community

• Weekly/bi-weekly outings • Fitness Center

• Restaurants

• Off-site dinner at faculty residence

• Walks across campus

• Using the “T” (Boston’s subway)

• Spouse/family member inclusion

Home Program

Summary of 2012 Treatment

• SLP Program • Individual Treatment

• Group Treatment

• Dyadic Treatment

• Carryover of goals across all contexts and into community

• Interdisciplinary

Results

Speech-Language Outcomes

Mean Performance by Group Across Multiple Baselines

p=.02* p=.02*

p=.02* p=.03*

Mean Performance by Group Across Multiple Baselines

p=.02*

p=.08

p=.03*

p=1.0

Mean Performance by Subject Across Multiple Baselines

p=.263

p=.04 p=.08

p=.02 *

*

Mean Performance by Subject Across Multiple Baselines

p=.32

p=.02 p=.012

p=.018

*

*

*

Outcomes for Picture Description

• Clients as a group produced narratives closer to “normal range” in terms of: • Number of words produced

• Percentage of content words

• Efficiency of speech

• Index of Grammatical Support (use of bound morphemes)

Quality of Life Measures

0

1

2

3

4

5

6

7

Pre TxPost Tx

Pre TxPost Tx

ASHA FACS

SIS

Mean Scores

p= .005

p= <.001

Case Example

PNT Pre-treatment (Baseline 1)

PNT Post-Treatment (Baseline 4)

Physical Therapy Outcomes

PT: Improvements in Community Walking

Six Minute Walk Test Pre & Post Intervention

0

100

200

300

400

500

600

700

1 2 3 4 5 6 7 8

Meets criteria for clinically meaningful change

Subjects 1 through 5 had a clinically meaningful change (>13%) in walking speed

Pre-intervention Post Intervention

Occupational Therapy Outcomes

The Meaningful Activity Participation Assessment (MAPA) (Eakman, Carlson, & Clark, 2010)

Participants

*Participant #2 results excluded from MAPA analysis due to change in status unrelated to program (surgery, in w/c) **Wilcoxon Signed Rank Test p=.028

Sum

of (M

eani

ngfu

lnes

s x

freq

uenc

y)

Motor Activity Log: Amount (Uswatte, Taub, Morris, Light, & Thompson, 2006)

Participants

p=.025

Resp

onse

*

Participants

Resp

onse

*

p=.017

The Wolf Motor Function Test (WMFT) (Wolf, Catlin, Ellis, Archer, Morgan, & Piacentino, 2001)

Participants

Sec

onds

**Wilcoxon Signed Rank Test p=.036

A few notable qualitative changes

• During the program, one individual completed volunteer application for Rosie’s place; recently attended orientation; to begin volunteering weekly

• At August reunion, one individual was excited to show the occupational therapist a video he took (on his iPad) of activities he is currently doing at home using affected upper extremity

• During first trip to FitRec, one individual was extremely fearful of taking bus but then excited to realize he could ask for the ramp; did this independently during the following weekly trips

Nutrition Outcomes

Eating Assessment Table (EAT)

• Pre and post eating practices assessed with EAT

• EAT yields a global score of nutrition quality for 11 domains (maximum 100)

• Group mean score increased from 55.5 to 59.9 (p=.004)

Govig B, Critical Pathways in Cardiology, (2009)

Participant weight and BMI

• Pre program • 3 obese (BMI >30) • 3 overweight (BMI 25-29.9) • 2 normal weight (BMI 19-24.9)

• Post program • 4 of 6 overweight or obese participants lost weight

(mean 5 pounds) • 1 participant was not weighed due to injury • 1 participant gained 7.5 pounds

Feedback from a participant

Liz,

It is marvelous. It is deeper level. I am reading, am crying, etc.

Month five days and five hours. Good thing. Thank you, Liz, I am speaking(?).

S is sweet. No cost, I like it.

I think, I can, I think, I can, etc.

Liz, thank you, so much.

M

Sent from my iPad

Feedback from a Spouse Dear Liz,

K had just begun to communicate more effectively this spring, but the intensive treatment program was a catalyst for much better communication. And K wants to socialize more now than he did before beginning the program. Having the IPad continues to be very helpful and allows us to continue with some aspects of the program. I loved it when K made a joke, at his own expense of course, at Friday's closing session.

I think the program worked for K as a result of a combination of several factors: experiencing superb speech therapy, bonding with others in the group, feeling a little more optimistic seeing how others had progressed, working with excellent dedicated caring professionals, being in a program every day all day for a month, learning to use the IPad. We wish the program could go on forever. Even though K was tired at the end of each day, he loved going and wanted me to know how outstanding he thought the staff and students were. Now that you know him, perhaps you realize how critical he can be; so, when he thinks something is very good, across the board, it's amazing and says a great deal about the quality of the program.

I wish I could make constructive suggestions that you would find helpful, but I can't. Your work gets an A+ from me.

I am deeply grateful to staff, students and S, We have received an enormous gift.

Regards,

XXXX

Feedback from a participant’s sister

A made some great improvements with the use of his arm and hand. Prior to the school, and up to and including the first week or two, I would cut A’s meat for him and make sure that he could eat comfortably the food on his plate. I started to notice that A began cutting his own food and also did this in front of guests that I had at the house.

On another note, his selections for food, at least breakfast started to include some healthy food, i.e., yogurt. On a whole A eats pretty healthy but started to add other healthy food to his routine.

Another noticeable good point is that he would start to bring his dirty dishes and cups to the kitchen and at least placing them in the sink.

As for language he spoke with guests that I had at the house which were people I had to dinner with A before he got into the program. He spoke in sentences and he even told me he spoke magnificent. He always put forth a happy face as such and always thought positive about the class and the people in it etc.

Lasting Changes…..

• Participation in ARC

• Participation in Aphasia Research Lab

• Volunteer in BU teaching

• Return to work

• Spouse/client involvement in aphasia community

Discussion

• What were the key ingredients contributing to success? • Intensity

• interdisciplinary

• customized goals

• Explicit training across contexts (levels of language code, individual to group, environment)

Resources/Cost

• Faculty/Staff in FTEs: • 2.2 SLPs • 0.5 OT • 1.0 (2 half-time) PTs • 0.2 RD

• Students: • One SLP graduate intern • 10 SLP graduate students each contributing ~ 2-3

hours/week on average. • 2 OT graduate students • 3 PT graduate students

Next Steps

• Repeat study using multiple baselines in all disciplines.

• Apply for grant funding to study efficacy via randomized controlled trial.

• Need for data to justify cost and to convince insurance companies to support these types of programming.

Acknowledgements

• Treatment Team: • Tami Rork (PT) • Stacey Zawacki (RD) • Susan Berger (OT) • Marianne Connor (SLP

• Research Collaborators • Gloria Waters • David Caplan • Terry Ellis • Swathi Kiran

• Stephen Weber

Selected References Basso, A., (2005). How intensive/prolonged should an intensive/prolonged treatment be? Aphasiology, 19, 975-984

Bhogal, S.K., Teasell, R.., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 3, 987-993

Bowden, M., Balasubramanian, C., et al. (2008). Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabilitation and neural repair, 22(6): 672.

Brookshire, R. H. & Nicholas, L. E. (1993). The discourse comprehension test. Tucson, AZ: Communication Skill Builders/The Psychological Corporation.

Caplan, D. & Bub, D. (1990). Psycholinguistic assessment of aphasia. Mini-seminar presented at the annual convention of the American Speech-Language-Hearing Association, Seattle, WA.

Carr, J. H., Shepherd, R. B., Nordholm, L. & Lynne, D. (1985). Investigation of a new motor assessment scale for stroke patients. Physical Therapy, 65(2), 175-180.

Duncan, P. W., Wallace, D., et al. The stroke impact scale version 2.0. (1999). Evaluation of reliability, validity, and sensitivity to change. Stroke; 30: 2131-2140.

Elman, R.J., Bernstein-Ellis, E., (1999). The efficacy of group communication treatment in adults with chronic aphasia. Journal of Speech, Language and Hearing Research, 42, 411-419.

Selected References Fulk GD, Echternach JL, NL, O’Sullivan S. (2008). Clinometric properties of the six-minute walk test in individuals undergoing rehabilitation poststroke. Physiother Theory Pract., 24:195-204.

Franchignoni F, Horak F, Godi M, Nardone A, Giordano A (2010) Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med.; 42(4):323-31.

Govig, B., Souza, RD., Levita, EB., Crookston, D., Kestens, Y., Mendivil, CO & Mittleman, M. (2009). The eating assessment table-an evidence-based nutrition tool for clinicians. Critical Pathways in Cardiology, 8 (2): 55-62.

Jonsdottir, J. and Cattaneo, D. (2007). Reliability and validity of the dynamic gait index in persons with chronic stroke. Archives of physical medicine and rehabilitation. 88(11): 1410-1415.

Kagan, A., Simmons-Mackie, N, Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., & Dickey, L., (2010). Assessment for Living with Ahasia. Toronto: Aphasia Institute.

Selected References

• Law, M., Baptiste, S., Carswell, A., McColl, M.A., Polatajko, H. & Pollock, N. (2005).The Canadian Occupational Performance Measure (4th ed.). Canada: CAOT Publications.

• Martin, N, Thompson, C, and Worral, L (2007) Aphasia Rehabilitation The Impairment and its consequences. Plural Publishing, San Diego, CA

• Roach, A., Schwartz, M.F., Martin, N., Grewal, R.s., & Brecher, A. (1996). The Philadelphia Naming Test: Scoring and rationale. Clinical Aphasiology, 24, 121-133

• Robey, R.R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. Journal of Speech, Language and Hearing Research, 41, 172-187.

• Porch, B.E., (1967). Porch Index of Communicative Ability. Palo Alto: Psychologists Press.

• Pulvermuller, F., Neininger, B., Elbert, T., Moh, B., Rockstroh, B., Koebbel, P., Taub, E. (2001). Contraint-induced therapy of chronic aphasia after stroke. Stroke, 32:1621-1626

Selected References

Schembre, SM & Geller, KS. (2011). Psychometric properties and construct validity of the weight-related eating questionnaire in a diverse population. Obesity, 1-7

Strauss, E.; Sherman, E.M.S.; Spreen, O. (2006). A Compendium of neuropsychological tests: Administration, norms, and commentary. (3rd. ed.). NY. Oxford University Press. Page(s): 499-526.

Thompson, C. K. (2002). The Northwestern Verb Production Battery. Unpublished.

Uswatte, G., Taub, E., Morris, D., Light, K. & Thompson, P.A. (2006). The Motor Activity Log-28: Assessing daily use of the hemiparetic arm after stroke. Neurology, 67, 1189-1194

Wertz, R.T., Collins, M.J., Weiss, D.G., Kurtke, j.F., Freiden, T., Brookshire, R.H., Pierce, J., Holzapple, P., Matovitch, V., Mortey, G.K., Resurreccion, E. (1981). Veterans Administration cooperative study on aphasia; a comparison of individual and group treatment Journal of Speech Hearing Res. 24, 580-594

Thompson, C. K. (2002). The Northwestern Verb Production Battery. Unpublished.

Uswatte, G., Taub, E., Morris, D., Light, K. & Thompson, P.A. (2006). The Motor Activity Log-28: Assessing daily use of the hemiparetic arm after stroke. Neurology, 67, 1189-1194

Additional Slides

Pilot Study: PT Outcome Measures for Gait

Six Minute Walk Test (endurance)

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Ten Meter Walk Test (speed)

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post(seconds)

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Mean Group Scores

Met

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Pilot Study: PT Outcome Measures for Balance

Dynamic Gait Index

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Pilot Study: OT Outcomes: UE Use Self-Rating Scales

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Canadian Occupational Performance Measure Motor Activity Log

p = 0.003 p= 0.341

p= 0.006 p= 0.022

Pilot Study: Nutrition Outcomes: Weight Loss

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Pilot Study: Nutrition Outcomes: BMI Change

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