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Elizabeth Rochon, Ph.D. Dept. of Speech-Language Pathology, University of Toronto Toronto Rehabilitation Institute- UHN Heart & Stroke Foundation Centre for Stroke Recovery
March 25, 2013
Speech Language Pathologist Southwestern Ontario Stroke Network Workshop
Facts about aphasia
Review of the evidence
Language specific approaches
Treating anomia at different levels
Multi-modality approaches
2
Incidence of aphasia reported to range from 23% (Lubart et al., 2005) to 35% after first-ever ischemic stroke (Lubart et al., 2005 ; Tsouli et al., 2009).
35% admitted stroke patients had aphasia at time of discharge (Dickey et al., 2010).
There are over 100,000 Canadians living with aphasia (Aphasia Institute)
It is estimated that approximately 1,000,000 individuals in the United States have aphasia. Source : http://www.asha.org/research/reports/stroke/
3
Compared to stroke patients without aphasia, patients with aphasia: Are older; Are more frequently female have more severe strokes; Have longer hospital stays; Have higher in-hospital mortality rate have more severe disability; Are at greater risk for depression Are discharged to long-term care and/or rehab more frequently Are less likely to return to work (even younger patients) Have higher rates of thrombolytic therapy
(Gialanella et al., 2011; Graham et al., 2011;Dickey et al., 2010; Bersano et al., 2009;Tsouli et al., 2009; Engelter et al., 2006; Provincialli & Coccia, 2002; )
4
Among 60 diseases and 15 health conditions, aphasia found to have the largest negative relationship with a health-related quality of life measure (HRQoL) in long-term care settings (Lam & Wodchis, 2010)
Out of 10 research priorities set by stroke survivors, families and health professionals in the U.K., recovery from and coping with aphasia were priority #3 and #8. (Pollock et al., 2012)
5
Aphasia leads to significant impairment, disability and handicap with effects felt for the individual, their family/friends and society at the levels of body structures/functions, activity and participation (i.e., ICF, WHO, 2001)
Evidence base for efficacy and effectiveness of aphasia treatment is growing (see Brady et al., 2012, Cochrane review; EBRSR.com; and others)
Recent attempts to evaluate quality of evidence
Questions remain about: Timing Intensity Specificity of Treatment
6
Speech-language therapy is better than no therapy:
Evidence noted especially for functional communication, receptive and expressive language
Insufficient evidence to adjudicate between one type of speech therapy approach vs. another
(The Cochrane Collaboration, 2012; see also Robey, 1998)
7
Treatment study designs: Systematic reviews 3%
RCTs 7%
Non-RCTs 5%
Case series 15%
Single-Subject designs 70%
(Up to September, 2007, n=339 aphasia treatment studies: Togher et al.,
2009)
8
Bhogal et al., 2002 Intensive treatment (i.e., more hours per week) yields better
outcomes)
E.g., half of the +ve studies provided an average of 8.8 hours/week for 11.2 weeks.; -ve studies provided approximately 1 hour/week for 22.9 weeks
Total hours of therapy were greater in more intense studies
“Intensive therapy delivered over 2 to 3 months is critical to maximizing aphasia recovery….” (p. 991)
(n=10 controlled trials, i.e., treatment vs. control condition)
9
Cicerone et al., 2011 No advantage for intensive therapy in acute stage
Contraint Induced Language Therapy (CILT) and training in everyday communication > CILT alone
Semantic & phonological treatment equally effective: treatment-specific effects demonstrated
10
Simmons-Mackie et al., 2010 Training communication partners improves their
communication activities and/or participation
Training communication partners is probably effective at improving communication activities and/or participation of persons with aphasia
Insufficient evidence for effects on: acute aphasia; impact on language impairment, psychological adjustment, or QOL
11
Faroqi-Shah et al., 2010 Treatment in L2 yields similar outcomes to treatment in L1
Cross-language transfer occurred in most studies
Conclusion limited by methodological quality of studies (n=14)
12
Allen et al., 2012 Treatment effective more than 6 mos. post stroke for:
Computer-based
CILT
Intensity
Group therapy
Conversation/communication partners
Electrical stimulation (TMS and TDCS) + drugs (piracetam, donepezil, memantine, galantamine) = effective
Filmed language instruction and bromocriptine not effective
13
Aphasia Therapy: What have we learned from an evidence-based practice database (PsychBITE)?
IX.
14
Selected Key Points:
Language therapy is most effective when provided intensely Constraint-induced aphasia therapy (CILT) may improve
language and functional communication Trained volunteers can provide effective adjunct to SLP
intervention Supportive Conversation for Adults with Aphasia (SCATM)
improves conversational skill Computer based treatment improves language and may improve
functional communication
15
Selected Key Points:
Cognitive linguistic and/or semantic or phonologically-based treatment improves language/word finding abilities
Evidence is insufficient regarding remotely administered and monitored therapy
Treatment with repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may improve naming in chronic aphasia
Piracetam or Dextroamphetamine in combination with language treatment can be beneficial
(See also PEDro & StrokEngine; PsycBITETM: www.psycbite.com; speechBITETM: www.speechbite.com)
16
Language Specific Approaches
Treating naming impairments in aphasia using Phonological Components Analysis (PCA) Treatment
Phonological Treatments:
o Reading a word aloud or Repetition (e.g., Hillis et al., 1994; Jokel et al., 1996; Miceli et al., 1996; Vitali et al., 2010).
Semantic Treatments:
o Word-to-picture matching tasks (e.g., Hillis et al., 1994; Howard et al., 1985; Marshall et al., 1990; Nickels et al., 1996).
Combination Treatments:
o Combination of phonological and semantic treatment in some patients (Wambaugh et al., 2001; Martin et al., 2006; Lorentz & Ziegler, 2009).
19
Treatment approaches based upon theoretical models of word production (Foygel & Dell, 2000)
20
Semantics (conceptual level)
FOG DOG RAT CAT MAT
f d g ae r o t k m Onsets Vowels Codas
Phonological
Words (lexical
semantics)
Developed a phonologically-based treatment, Phonological Components Analysis (PCA), modeled on Semantic Feature Analysis (SFA) (Coelho et al., 2000; Boyle, 2004).
Goals: document efficacy of PCA, including effects of maintenance and generalization;
Investigate changes in neural activation as a function of treatment.
21 Leonard, Rochon, & Laird, 2008, Aphasiology
Patient Gender Age Education YPO Diagnosis
P1 M 71 13 12 Broca's
P2 M 57 8 3 Broca's
P3 F 50 21 1 Broca's
P4 F 65 14 14 Anomia
P5 F 50 16 3.5 Broca's
P6 M 73 12 4 Mixed Nonfluent
P7 M 57 6 17 Broca's
P8 M 52 18 6.5 Broca's
P9 F 72 12 1.5 Wernickes
P10 M 70 19 2.5 Anomia
Mean 62 14 7
Median 61 14 4
22
(Foygel & Dell, 2000)
Semantics (conceptual level)
FOG DOG RAT CAT MAT
f d g ae r o t k m
Onsets Vowels Codas Phonological
Words (lexical
semantics)
IMPAIRED
23
Rhymes with
SHED
Starts with
SyllablesWord Association Ends with
/ b /
BALL 1/ d /
Rhymes with
SHED
Starts with
SyllablesWord Association Ends with
/ b /
BALL 1/ d /
24 Leonard, Rochon, & Laird, 2008, Aphasiology
Group Association
Location Properties Action/Use
furniture
for sleeping soft house/room
night-time
26
Single-subject design Multiple baseline across behaviours
Treatment administered 3 times /week.
Probes administered every 2nd session (every 3rd
session for untreated lists).
Criterion: 80% over two consecutive probe sessions or a maximum of 15 sessions.
27
28
Participants
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
List 1 NA NA NA
List 2 NA NA NA
List 3 NT X NA NA NA
Participant Mean Effect Size P1 7.20 P2 2.65 P3 8.70 P4 2.80 P5 3.00 P6 3.47 P8 6.80
All participants had a large effect size according to Busk & Serlin, 1992
29
Phonologically-based treatment appears to have been
efficacious (with good maintenance and generalization effects).
Stimulating connections within the phonological “network” for a given target word appears to result in activation of semantic nodes (via feedback) and make a word more accessible for production.
What might be the social validation effects and the activation patterns in the brain associated with improvement in PCA treatment?
30
Social validation of PCA treatment
Technique that aims to assess the “clinical relevance of changes made during treatment” (Kazdin, 1977).
To be used in conjunction with objective language measures.
In aphasia treatment studies: Assessment tool in which raters, not involved in the treatment
process are asked to evaluate pre- and post-treatment language samples.
Participants:
People with aphasia 11 participants – naming treatment study (Leonard, Rochon, & Laird, 2008,
Aphasiology; Rochon, Leonard, Laird et al., 2010).
4 participants: treated - improved 3 participants: treated - no change 4 participants: control group
Raters 3 groups
10 speech-language pathologists (SLP), mean age: 37.3 10 younger naïve adults (YA), mean age: 35.4 10 older naïve adults (OA), mean age: 66.6
Materials Cinderella narratives (Saffran et al., 1989; Berndt et al., 2000).
Pre- and post-treatment retellings.
Order of narratives randomized and counterbalanced across raters and sessions.
Pre- and post-treatment narratives of each patient presented together.
Extremely Poor Very Poor Poor Adequate Well Very Well Extremely Well 1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
Cinderella 1a)
1. Amount of information provided in the narrative.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
2. Person’s ability to transmit the message.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
3. Person’s ability to find the adequatete words.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
4. Degree of ease in retelling the narrative.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
Extremely Poor Very Poor Poor Adequate Well Very Well Extremely Well 1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
Cinderella 1a)
1. Amount of information provided in the narrative.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
2. Person’s ability to transmit the message.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
3. Person’s ability to find the adequatete words.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
4. Degree of ease in retelling the narrative.
1 2 3 4 5
Extremely Poor Very Poor Poor Adequate Well Very Well Extremely Well 1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
Cinderella 1a)
1. Amount of information provided in the narrative.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
2. Person’s ability to transmit the message.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
3. Person’s ability to find the adequatete words.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
4. Degree of ease in retelling the narrative.
1 2 3 4 5 6 7+------------+------------+------------+------------+------------+------------+
*
*
*
*LeDorze et al., (1994)
2 sessions (1 ½ hours each).
Raters were asked to listen to each narrative, and rate it on the 4 parameters.
Raters were blind to the purpose of the experiment.
(composite score)
1
2
3
4
PRE POST
Pre- vs. Post-treatment
Rat
ing
(1-4
SLP
OA
YA
(composite score)
1
2
3
4
PRE POST
Pre- vs. Post-treatment
Rat
ing
(1-
4)
SLPOAYA
(composite score)
1
2
3
4
PRE POST
Pre- vs. Post-treatment
Rat
ing
(1-4
SLP
OA
YA
• Raters are ‘sensitive enough’ to distinguish between different groups of speakers.
• There is an additional value to the treatment, that was not detected by the objective language measures.
• Could be easily implemented in a clinical setting.
An investigation of the neural changes associated with improved naming using fMRI
(see also Kleim, 2011 & Kolb, Muhammad & Gibb, 2011; Cramer et al., 2011;
Krakauer et al., 2012)
45
Kleim & Jones, (2008), JSLHR
Domain specificity in optimizing training and experience in
neurorehabilitation (Cramer et al., 2011)
Individualizing therapy maximize the opportunity for neural plasticity within specific domains ultimately enhance functional outcome (Kleim, 2011)
Possibility of domains or impairment-driven treatment to elucidate mechanism(s) of repair and neuroplasticity (Krakauer et al., 2012)
46
Debate regarding the role of the right versus the left hemisphere in recovery of language function.
1. Evidence of right hemisphere adaptation (e.g., Abo et al., 2004; Peck et al., 2004; Meinzer et al., 2006; Fridriksson et al., 2009).
2. Evidence of left hemisphere perilesional activity (e.g., Léger et al., 2002; Cornelissen et al., 2003; Brier et al., 2004; Crosson et al., 2005; Price & Crinion, 2005; Meinzer et al ., 2008; Fridriksson et al., 2010; Postman-Caucheteux et al., 2010).
3. Evidence of bilateral activation (e.g., Leger et al., 2002; Fridriksson et al., 2006; Meinzer et al., 2007; Sebastian & Kiran, 2011; see Vitali et al., 2010)
47
fMRI Methods Participants
Healthy Controls o 10 healthy controls o right-handed adults o 3 women & 7 men o Age range: 44-88 years
Patients in Treatment
o 2 patients with aphasia (P5,P6) o Right-handed o 1 man & 1 woman o Ages: 50 & 73 years
Control Patients o 2 control patients with aphasia (C1,C2) o Right-handed o 2 men o Ages: 83 & 63 years
48 Rochon, E., Leonard, C., Burianova, H., Laird, L., Soros, P., Graham, S., Grady, C. (2010). Brain and Language.
Procedure
Patients who received treatment were scanned before and after treatment.
Control participants were scanned twice, approximately 3.5 months apart.
Scans obtained using a 3.0 Tesla system. For blood oxygenation-level-dependant (BOLD) fMRI, T2*-weighted functional images were acquired using a spiral-in/out pulse sequence.
49
Control Task 4 items (8 sec)
Experimental Semantic Judgment Task
“Which picture on the bottom is related in meaning to the picture on the top?”
Experimental Task 4 items (8 sec)
Baseline Task 4 items (8 sec)
“Press the button each time you see the cross appear on the screen”
“Which picture on the bottom is the same size as the picture on the top?”
Time
Participant’s response is by button press
+
50
Experimental Rhyme Judgment Task Experimental Task 4 items (8 sec)
Baseline Task 4 items (8 sec)
“Press the button each time you see the cross appear on the screen”
Participant’s response is by button press
Control Task 4 items (8 sec)
Time
“Do the names of these pictures rhyme, yes or no?”
“Are these pictures the same size, yes or no?”
+
51
Data were preprocessed using Independent Components Analysis (ICA). (Kochiyama, 2005; Stone, 2002).
For single subject analyses individual Partial Least Squares (PLS) was used (McIntosh & Lobaugh, 2004; McIntosh et al., 2004).
PLS examines the covariance between activity in all brain
voxels, and provides sets of mutually independent spatial patterns depicting brain regions that show the strongest relation to the contrasts across tasks.
The PLS analysis contrasted patterns of brain activity contained within the fMRI data across conditions and across scan 1 and scan 2.
52
Results of the analysis comparing activations in the phonological and semantic tasks for scans 1 and 2 for P5 with representative areas of activation on the semantic task.
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
PhonologicalSemantic
Des
ign
Scor
es
Scan 1 Scan 2
L IFG z = 8
R STG z = 0
L MTG z = 24
L IFG z = 8L IFG z = 8
R STG z = 0
R STG z = 0
L MTG z = 24
L MTG z = 24
IFG= inferior frontal gyrus MTG=middle temporal gyrus STG=superior temporal gyrus 53
Results of the analysis comparing activations in the phonological and semantic tasks for scans 1 and 2 for P6 with representative areas of activation on the semantic task.
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
PhonologicalSemantic
Des
ign
Scor
es
Scan 1 Scan 2
L IFG R MFGz = 8 z = 52
L MFGz = 0
L SMGz =32
L IFG R MFGz = 8 z = 52L IFG R MFGz = 8 z = 52
L MFGz = 0
L MFGz = 0
L SMGz =32
L SMGz =32
SMG= supramarginal gyrus MFG= middle frontal gyrus IFG = inferior frontal gyrus 54
Summary/Conclusions
After phonologically-based therapy activation patterns changed during the semantic task.
Areas identified as important for phonological and semantic processing were activated in the semantic task for treated patients (i.e., LIFG, MTG, IP).
More left hemisphere activation noted after treatment for treated patients.
55
Bilateral activation continued to be present, especially in control patients.
Areas not traditionally associated with language processing were also activated in treated and control patients.
Findings support the notion of neuroplasticity even in chronic stages of aphasia in that there were changes in brain activations associated with improved naming.
Next study manipulates a task factor, the element of choice, in two different treatment conditions
Summary/Conclusions
56
Manipulating “choice” in PCA therapy
Leonard,C., Rochon E., Laird, L., Burianová, H., Simic, T., Graham, S.,
Grady, G. Behavioural and Neural Changes after a “Choice” Therapy for
Naming Deficits in Aphasia: Preliminary Findings. (under review)
Hickin et al. (2002) have identified the importance of choice to improvement in treatment. They argue that perhaps a more active engagement of the participant in his/her therapy
is necessary to produce longer lasting effects.
In our treatment protocol, the phonological components were not simply supplied to the participants. Participants were provided with the opportunity to generate and/or choose their own for
a given target word.
Interestingly, all 3 of the individuals who did not show a treatment effect were only successful at generating their own phonological components less than 50% of the time.
Fillingham et al. (2005a; 2005b) and others (Robertson & Murre 1999; Turner & Levine, 2004) have argued that (frontal) executive systems in particular are crucial for rehabilitation
Treatment task factors have an influence on neural plasticity (Thompson et al., 2010; Rapp et al., 2013)
To systematically explore the possibility that active engagement of the participant in choosing phonological components will better promote maintenance of effects and generalization to untrained stimuli.
To investigate the changes in neural activation as a function of treatment, especially in relation to activation in frontal areas.
Participants were randomly assigned to Treatment A (Choice) or B (No Choice).
In the Choice condition, participants were given the opportunity to provide their own response and/or chose from a list.
In the No Choice condition, the participants were always provided with the response.
Responses (on Baseline, Post Tx & Follow-up) were rated on a 4 point scale (Huber et al., 1983).
0 = Incorrect
1 = Semantic or Phonological paraphasia
2 = Semantic or Phonological paraphasia with immediate self-correction of target word
3 = Correct response
Performance between Baseline and Post Treatment (Tx), 4 & 8 week Follow-up (FU) was significantly different for all participants (Wilcoxon Signed Ranks Test, p < .017) except for Participant 3 on Baseline vs. 8 week Follow-up.
Effect sizes for all participants were found to be medium to large (Busk & Serlin, 1992).
Treatment effect sizes per participant
Choice
No Choice
Generalization on the PNT was found for 3/5 participants 1(Roach et al. 1996).
Table 4. Percent correct on Philadelphia Naming test (PNT)1
Choice
No Choice
66
P2
Comparison phonological and baseline tasks at scans 1&2 . LV1 at scan 1. Red positive correlation with phonological task; Blue positive correlation with baseline task.
67
P2
Comparison phonological and baseline tasks at scan 1&2 . LV2 at scan 1. Red positive correlation with phonological task; Blue positive correlation with baseline task. • L & R frontal areas • Thalamus • R middle occipital gyrus • Precuneus
68
P2
Comparison semantic and baseline tasks at scans 1&2 . LV2 at scan 1 Red positive correlation with phonological task; Blue positive correlation with baseline task. • L & R frontal pre frontal regions • L cingulate gyrus • L middle temporal gyrus • R insula
69
P4
Comparison phonological and baseline tasks LV1 activation at scan 1. Red positive correlation with phonological task; Blue positive correlation with baseline task. • L & R inferior frontal gyrus • R SFG superior frontal gyrus
70
P4
Comparison semantic and baseline tasks LV1 activation both before and after treatment. Red positive correlation with semantic task; Blue positive correlation with baseline task. • L frontal areas • L cingulate • R lingual gyrus
Summary/Conclusion
Both participants’ naming improved BUT
P2 (choice condition) but not P4, showed a larger treatment effect size and generalization to a novel task (with untrained words)
AND
P2 but not P4, showed neural activation post treatment in left and right prefrontal regions.
This may point to potential role of attention/executive control systems in treatment gains
We plan to investigate this relationship in a future study.
71
Summary/Conclusion
Results in keeping with previous ones with PCA treatment (Rochon et al., 2010).
BUT here activation changes found on both tasks; changes on phonological task post treatment predominantly in right hemisphere,
Element of “choice” may have led to post-treatment activation changes on both tasks.
Right inferior frontal gyrus may have played a role due to lesion size (e.g., Meinzer et al., 2011).
Activation changes in left hemisphere after treatment for P2 in line with importance of left hemisphere activation for recovery (e.g., Fridrikson, 2010).
72
PCA Future Directions
Current study manipulating intense vs. standard PCA therapy, holding duration constant.
Investigating neural changes as a function of
intensity
73
A comparison of semantic feature analysis and phonological components analysis for the
treatment of naming impairments in aphasia
Van Hees, Angwin, A., McMahon, K., Copland, D. (2013). A comparison of semantic feature analysis and phonological components analysis for the treatment of naming impairments in aphasia. Neuropsychological Rehabilitation.
van Hees, et al.(2013). Neuropsychological Rehabilitation.
Figure 1. Naming accuracy data for each participant: B1-3= baseline 1-3 (pre-treatment, P1-P3 = Probe 1-3 (every 4th session during treatment), FU=Follow-up, PCA = items treated using Phonological Components Analysis, SFA= items treated using Semantic Feature Analysis, UNT = Untreated Items (*p<.05 **p<.01 ***p<.001)
van Hees, et al.(2013). Neuropsychological Rehabilitation.
Summary/Conclusion
7/8 participants improved with PCA; 6/7 maintained @ f/u.
4/8 improved with SFA; 3/4 maintained @ f/u Improvement not significant on untreated items (BNT),
though most showed trend to improvement 4 patients showed changes in connected speech (e.g.,
increased MLU, WPM, # different words) and 4 did not PCA found to be effective for patients with semantic
deficits Relationship between response to therapy and an
individuals’ locus of breakdown still needs further investigation.
77
Constraint Induced Language Therapy (CILT) Approach or Intensive
Language-action therapy (ILAT)
Two to four participants—typically one therapist and three patients with aphasia—sit around a table and play a game that requires verbal communication.
The aim of the barrier game is to obtain both cards of a pair by addressing verbal requests to the other participants. Requests are made verbally, with accompanying gesturing being encouraged.
Participants practice both speech production and comprehension in this context.
With minimal modifications they can also practice writing and reading. The difficulty level of the task can be adjusted to the patients’
capabilities and deficits by varying the materials
(From Berthier & Pulvermüller, 2011; see Pulvermüller et al., 2001) Note: very similar to PACE therapy (Davis & Wilcox, 1985; Carlomagno et al., 1991; Springer et al., 1991
80
(Berthier & Pulvermuller 2011)
81
Based on learned non-use hypothesis re: motor function from animal and human studies (e.g., Taub et al., 2002)
Improvements demonstrated on language tests and day-to-day communication (self rating)in individuals with chronic aphasia (e.g., Pulvermüller et al., 2001; Meinzer et al., 2005)
Approach has been modified to focus on: verb production (Goral & Kempler,2009 )
Agrammatism (Faroqi-Shah & Virion,2009)
Semantics, phonology, syntax (Szaflarski et al., 2008)
CILT + memantine led to better performance than CILT + placebo (Berthier et al., 2009)
82
Positive results early post stroke (3-5mos.; n=3) Greater gains in expressive vs. receptive abilities
Modifications due to inpatient rehab setting and patient stamina (Kirmess & Maher, 2010)
Increased noun (but not verb) production and informativeness in connected speech (Kirmess & Lind, 2011)
Drill + CILT increased verb naming; Communication-based + CILT increased sentence and
narrative structure (Kempler & Goral, 2011)
Recent article outlines the methods of ILAT (Difrancesco, Pulvermüller & Mohr, 2012)
83
(Meinzer et al., 2008)
84
Increased fMRI activity in perilesional ROIs after CILT therapy was correlated with treatment gains (Meinzer et al., 2008; see also Brier et al., 2009; and others)
BUT Richter et al., (2008) found correlation between changed activity in the right hemisphere and treatment success
85
At least 10-15 studies in 10 years re; this approach Most show at least some degree of improvement in chronic
aphasia after treatment of: language (i.e., on standardized tests), and/or functional communication, and/or connected speech
Questions remain re: treatment effects, e.g., 2 treatments of same intensity achieved similar effects (Barthel et al.,2008; 2006; see also Cherney et al., 2008; Dembowski, 2009 )
2 treatments differing in ‘forced use’ yielded better outcomes for CILT (Maher et al., 2006)
Questions remain re: underlying neural mechanisms of CILT-
induced recovery (see Meinzer et al., (2012) for review)
86
Social Approaches
Supported Conversation
Treatment based upon acknowledging and revealing
competence in person with aphasia Hierarchy of techniques taught to conversational partner
to facilitate conversation, enable expression, ensure comprehension
Trained volunteers improve at acknowledging and revealing competence
Individuals with aphasia improve on measures of social and message exchange skills (e.g., Kagan et al., 2001)
88
Supported conversation
Supported Conversation for Adults with Aphasia (SCATM)
89 Reprinted with permission from the Aphasia Institute
Computer Approaches
Computer therapy
Computerized (written) language exercises yielded
better outcomes on standardized tests than computerized non-language exercises (Katz & Wertz, 1997- Phase 3 efficacy trial)
Computerized therapy programs to: Improve naming (Doesborgh et al., 2004; Fink et al., 2005)
Written naming (Katz et al., 1989)
Reading comprehension (Katz & Nagy, 1985)
Sentence comprehension (Crerar et al., 1996)
Sentence production (Fink et al., 2008)
91
c2001, Albert Einstein Healthcare Network, Philadelph
Moss Talk Words (Phase 1 trials) shown to: Improve word naming in post stroke aphasia and primary
progressive aphasia; improve word comprehension (e.g., Fink et al., ASHA, 2010)
Multi-Cue Computerized semantic and phonological cueing:
improved language skills (Doesborgh et al., 2004)
93
Computer therapy
Script Training Clients practice scripts with computer avatar: improve in
communication skills (Manheim et al., 2009)
Computer Therapy compared to Usual Care Stepbystep (aphasia-software.com) individually
configured (by SLP) better than usual care (20% improvement in words correctly named) Little benefit to individuals with severe aphasia (Palmer et al., 2012)
94
Computer therapy
Non-invasive brain stimulation
Non-invasive brain stimulation
TMS = Transcranial Magnetic Stimulation
Magnetic pulses induce electrical currents that disrupt neuronal activity in cortex
Brain region goes ‘offline’ temporarily as a result Timing and frequency of pulses determine inhibitory or facilitatory effects
on cortical function rTMS = repetitive transcranial magnetic stimulation, applies rapidly
changing magnetic fields at low frequency to induce currents in cortex Transcranial direct current stimulation (tDCS) applies low intensity direct
currents Based upon the assumption that down-regulating activity in the non-
dominant hemisphere will allow language areas in the dominant hemisphere to be more susceptible to treatment (e.g., Martin et al., 2009; Thiel et al., 2006)
96
Non-invasive brain stimulation
rTMS over 10 days without speech therapy in 7 patients with nonfluent aphasia (over pars triangularis homologue) yielded improvements in naming and connected speech, maintained over 8 months (Barwood et al., 2012; see also Naeser et al., 2005a; 2005b).
tDCS to left perisylvian region has shown improved picture naming (Monti et al., 2008; Kang et al., 2011).
97
98
TMS and Aphasia Therapy
Patients received speech therapy and TMS over RH IFG (intervention group) or speech therapy and TMS over vertex (control group).
rTMS over homologue to Broca’s area preceding speech therapy in patients within 16 weeks poststroke, prevented shift of activity to right hemisphere and improved language function compared to patients receiving sham stimulation (Weiduschat et al., 2011).
Conclusions
In future functional and/or social approaches in combination with language-specific approaches may yield the greatest improvement.
Exciting advances in the combinations of technology-based and/or pharmacologically-based interventions with speech-language therapy may also yield significant improvement.
100
Conclusions
“Neuroscience of recovery and restoration” (Carter et al., 2010) has shown that: a. Even patients in chronic stages of recovery can evince
neuroplastic changes; b. Provides hypotheses for underlying mechanisms of recovery in
brain damage c. Will inform future treatment
Questions remain about: What treatments best suited in acute vs. chronic stages What the best allocation of SLP resources is in the acute vs.
chronic post stroke stages What aspects of treatment effect change Optimal service delivery models
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Conclusions
Aphasia treatment research is a relatively young field
Enhanced quality of research and clinical trials still needed to fully establish standards of care and practice guidelines
Cost and the burden of aphasia to the individual, to society and to healthcare system motivate a need to prioritize aphasia research and treatment and to ensure aphasia is well represented in stroke best practice guidelines (see: Kagan et al., 2012)
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Research Staff
Eleanor Arabia
Kitt Flynn
Hannah Jacobs
Lauren Reznick
Danna Rybko
Tina Simic
Ph.D. Students
Regina Jokel
Jennifer Cupit
Postdoctoral Fellows
Peter Sörös
Karine Marcotte
Referral Sites
York Durham Aphasia Centre
The Aphasia Institute
Baycrest
Sunnybrook Health Sciences Centre
TRI- University Health Network
Aphasia Center of Ottawa
FUNDING SOURCES
Heart & Stroke Foundation of Canada Heart& Stroke Centre for Stroke Recovery Canadian Institutes of Health Research
Collaborators
Carol Leonard
Cheryl Grady
Simon Graham
Hana Burianova
Laura Laird
Jed Meltzer
