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Const raint -I nduced Language T her apy

Rachael Aspeslet U n iv e r s it y o f W is co n s in - S t e v e n s P o i nt

According to the Post-Stroke Rehabilitation Guideline Panel, nearly 400,000 people have a stroke each year in the United States (as cited by Maher et al., 2006). Of those strokes, roughly 20% percent result in a moderate to severe aphasia. Aphasia can be defined as a severe impairment that effects both language production and comprehension (Meinzer, Djundja, Barthel, Elbert, & Rockstroh, 2005), among other impairments. Over the years, many theories and techniques have been developed to address the motor and language consequences of aphasia. A relatively new category of treatments known as constraint-induced therapies has been implemented to help improve the motoric and linguistic deficits of people with chronic aphasia. These treatments apply principles that counter the effects of learned non-use, in which individuals fail to regain specific abilities due to the use of compensatory strategies (Maher et al, 2006). Constraint-induced motor therapy (CIMT) was first introduced to prevent animals such as monkeys from losing function of damaged limbs by restraining the use of their unaffected limb. This forced the monkeys to regain strength and motor control in the affected limb(s) (Lillie & Mateer, 2006). Soon, this approach was applied to humans with motor issues resulting from brain damage (Cherney, Patterson, Raymer, Frymark, & Schooling, 2008; Lillie & Mateer, 2006). The apparent success of CIMT has led researches to consider whether the principle of constraint could be applied to language and cognition deficits as well (Lillie & Mateer, 2006; Szaflarski et al., 2008). Constraint-induced language therapy (CILT), sometimes referred to as constraint-induced aphasia therapy (CIAT), was introduced as a short term, intensive aphasia therapy (Cherney et al., 2008; Lillie & Mateer, 2006; Meinzer et al., 2005). The CILT approach incorporates three main principles: massed practice, shaping, and constraint of compensatory strategies (Meinzer et al., 2005; Meinzer et al., 2007; Barthel et al., 2008). The combination of these three principles is unique to the constraint-induced therapies.

Massed practice entails the intensity of treatment. Most patients who partake in CILT receive three to four hours of treatment per day for two weeks (Lillie & Mateer, 2006; Meinzer et al., 2005; Cherney et al., 2008). Shaping is the gradual and sequential increase in the difficulty of the language tasks employed during treatment (Barthel et al., 2008; Meinzer et al, 2005). These language tasks are individualized to match the clients capabilities (Lillie & Mateer, 2006; Meinzer et al., 2007). The constraint of compensatory strategies, also known as forced use of verbal language, inhibits the use of gestures, writing, and other non-verbal strategies and focuses on speech production alone (Cherney et al., 2008; Meinzer et al., 2005). This strategy forces clients to use a verbal method of expressive communication in order to inhibit the onset of learned non-use (Meinzer et al., 2007; Lillie & Mateer, 2006). Lillie and Mateer (2007) applied the learned non-use model to aphasia therapy, indicating that a failed communication attempt can lead to negative punishment of verbal language or positive reinforcement of compensatory strategies. Either way, the individuals learn to avoid verbal expression. The implications of the constraint principle are still controversial. For the past decade, many researchers have explored the effectiveness of CILT in people with aphasia. Research by Meinzer et al. (2005) found that treatment involving CILT can lead to long-term improvement and stability in language functioning in people with aphasia. Their single case study analyses revealed that 85% of the twenty-seven subjects showed significant improvement in at least one standardized language subtest. The study also evaluated the patients and family members thoughts about the individuals communication effectiveness. The results of the Communication Effectiveness Index (CETI) showed that families noticed better communication and comprehension at home. However, this study could not conclude

which of the three principles contributed most to the documented; constraint, massed practice, or shaping (Meinzer et al., 2005). A multiple single-subject study by Maher et al. (2006) compared the therapies of CILT and Promoting Aphasiac Communication Effectiveness (PACE). While participants in the CILT group were constrained to only verbal output, participants in the PACE group were allowed to use any mode of communication. The results indicated that participants in both groups made improvements during the short term treatment. To eliminate confounding variables, researchers provided the same intensity to both treatment groups; therefore, intensity alone cannot explain the positive outcomes of therapy. While the researchers concluded that CILT does in fact improve language functioning of people with aphasia, it is too early to conclude that CILT is more effective than other intensive treatments (Maher et al., 2006). A single subject study by Szaflarski et al. (2008) investigated the effectiveness of CILT on three participants. Results revealed an increase in auditory comprehension, the total number of words and utterances spoken, and the number of different words produced in conversation. However, no improvement was noted in the expressive component of standardized tests or in the patients perception of speech fluency and easiness. Szaflarski et al. (2008) had no comparison group for this study and the sample size was only three individuals, so further research is necessary to obtain more supported conclusions. A randomized-control study by Meinzer et al. (2007) considered using family members or lay people as therapists in CILT. Results indicated that patients were more motivated to work with their family members than with trained professionals. Subjects in both groups made significant improvements in language tasks. Researchers concluded that the what (type of

treatment: CILT) rather than the who (person providing treatment) was responsible for the positive outcomes on language functioning (Meinzer et al, 2007). Barthel et al. (2008) compared CILT to intensive model-oriented aphasia therapy (MOAT) to identify which aspects of aphasia therapy contribute most. Research confirmed that improvement of language abilities were achieved by both CILT and MOAT. Subjects in the MOAT group improved more in written language tasks as well as naming untrained items than those in the CILT group. These findings suggest that the principle of constraint may not necessarily be an obligatory component of improved language functioning. Despite the variability and inconsistency of research pertaining to CILT, it appears that individuals with aphasia improve in various language tasks as the result its implementation. It may remain unknown to which of the principles of CILT (massed practice, shaping, or constraint) contributes most to improvement. The evidence I gathered included a systematic review, randomized controlled studies, and multiple single-subject studies, which are sources of comparitively strong support. However, weak evidence in my research included a study without a control group and a few studies with small subject sizes. Overall, the strength of the evidence varies, but the majority of the research has the same outcome. Because CILT is a relatively new therapy approach, I would expect the research and evidence to continue to grow and strengthen in the coming years. Based on this research, I think I would be willing to give CILT a try in my own practice. However, a setback to this approach of aphasia therapy is the time commitment from the individual and the clinician. Implementation of this approach would depend on where I was employed and the time I have available for each client. Because CILT is implemented for three to four hours per day, the overall length of the treatment is quite brief (usually two weeks). Medical insurance may be more willing to cover the short-term treatment rather than traditional

aphasia approaches. Taken as a whole, this new approach has the potential to make a difference in the lives of people with chronic aphasia.

References Barthel, G., Meinzer, M, Djundja, D, & Rockstroh, B. (2008) Intensive language therapy in chronic aphasia: which aspects contribute most? Aphasiology, 22 (4), 408-421. doi:10.1080/02687030701415880 Cherney, L. R., Patterson, J. P., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidencebased 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, 1282-1299. doi:1092-4388/08/5105-1282 Lillie, R., & Mateer, C. A. (2006). Constraint-based therapies as a proposed model for cognitive rehabilitation. The Journal of Head Trauma Rehabilitation, 21(2), 119-130. Maher, L. M., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S. A., Pingel, K., Holland, A., & Gonzalez Rothi, L. J. (2006). A pilot study of use-dependent learning in the context of constraint-induced language therapy. Journal of International Neuropsychological Society, 12(6), 843-852. doi:10.1017/S1355617706061029 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. Journal of the American Heart Association, 36, 1462-1466. doi:10.1161/01.STR.0000169941.29831.2a Meinzer, M., Streiftau, S., & Rockstroh B. (2007). Intensive language training in the rehabilitation of chronic aphasia: efficient training by laypersons. Journal of International Neuropsychological Society, 13, 846-853. doi: 10.1017/S1355617707071111

Szaflarski, J. P., Ball, A. L., Grether, S., Al-fwaress, F., Griffith, N. M., Neils-Strunjas, J., Newmeyer, A., & Reichhardt, R. (2008). Constraint-induced aphasia therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Med Sci Monit., 14(5), 243-250.