Aphasia Treatment

Evidence-based Practice The State

of the Evidence
Janet Patterson, Ph.D., CCC-SLP
VA Northern California Healthcare System
Martinez CA
and
California State University East Bay
Hayward CA

Session Two
Activity/Participation-based Treatment
Treatment Delivery

Emerging Treatment Techniques

Objectives
Identify evidence for activity/participation-based
treatment techniques
Identify evidence for emerging treatment
techniques
Identify considerations for successful treatment
outcome

ACTIVITY/PARTICIPATION BASED
TREATMENT TECHNIQUES

Outcome Measures
Test results
Connected speech
CIUs (Brookshire & Nicholas, 1993)
Content units (Yorkston & Beukelman, 1980)

Perceptual data
Interview with PWA, family, friends or associates
(Lomas et al., 1989)

Activity reports and surveys

ADLs, social occasions, conversation, job success

Quality of life (Hilary, Byng, Lamping & Smith, 2004)

Blackstone & Hunt Berg, 2006

Life Participation Approach to Aphasia

Core Components
The explicit goal is enhancement of life participation.
All those affected by aphasia are entitled to service.
Both personal and environmental factors are targets of
assessment and intervention.
Success is measured via documented life enhancement
changes.
Emphasis is placed on availability of services as needed at all
stages of life with aphasia.
Chapey, Duchan, Elman, Garcia, Kagan, Lyon & Simmons Mackie (1999)

Activity/Participation-based
treatment techniques
Group treatment
Conversation participation
Treatment for caregivers or conversation
partners
Personal narratives; scripts
AAC

GROUP TREATMENT

Types of Group Treatment

Goal-directed
Conversation participation (Simmons-Mackie, 2000; Vickers, 1998)
Specific linguistic goal
Cooperative learning (Avent, 1997)
Reading and writing (Cherney, Merbitz & Grip, 1986; Clausen & Beeson, 2003)
Life activities (i.e. book group (Bernstein Ellis & Elman, 2006))
Support (www.naa.org)
Information (Avent, Glista, Wallace, Jackson, Nishioka &Yip, 2004)

Evidence, ES and Conclusions

Effect Sizes for Group vs. Individual Treatment
--- RCTs --WAB AQ
WAB AQ
Token Test
Token Test
PICA Verbal Subtest
PICA Overall
PICA Graphic
PICA Gestural Subtest
AAT Repetition Subtest
AAT Overall
AAT Naming Subtest
AAT Comprehension Subtest
-5.1

-0.1

4.9

9.9

14.9

19.9

24.9

29.9

34.9

39.9

Kelly, Brady, Enderby, 2010

Change Scores and Total Number of Participants for

Studies of Group Treatment
80
70

Change Score

60
50
40
30

Participants showing positive change

Number of participants

20
10
0

Salter, Teasell, Bhogal, Zettler & Foley (2010)

 RCTs
Inconsistent data supporting effectiveness of
group treatment over individual treatment
Limited support for social groups and language change

Other published studies

Moderate support for group treatment and
language change
Varying methodology and outcome measures

 Anecdotal and qualitative information

Improved quality of life (Avent & Austerman, 2003)
Feeling of community (Bernstein-Ellis & Elman, 1999)
Improved sense of self (Elman, 2007)
Safe environment in which to practice
People vote with their feet
Number of aphasia groups increasing
Expanded variety of group types
Book group, artistic expression, theater group, exercise group,
choral group

CONVERSATION PARTICIPATION

Script Training
Client and clinician create short, relevant
scripts
Repetition until mastery
Personal cues (Freed, Marshall, Nippold, 1995)
Computer directed (Cherney, Halper, Holland & Cole, 2008)
Speech-language pathologist as trainer (Youmans, Holland,
Muoz &Bourgeois, 2005)

Insertion into connected speech situation

Supported Conversation and Partner

Training
Communicative competence of a PWA can be
uncovered by a skilled partner
Typically family members or close friends
Consider layers of training

Partner changes
behavior so PWA
will change
Armstrong & Mortenson

Treatment Techniques
PACE

Promoting Aphasics Communicative Effectiveness (Davis & Wilcox, 1985)

Collaborative exchange of information

RET Response Elaboration Training (Kearns, 1985)

Expand utterance content

Conversational Coach (Hopper, Holland & Rewega, 2002)

Clinician coaches PWA and partner

Reciprocal Scaffolding(Avent & Austerman, 2003; Avent, Patterson, Lu & Small, 2009)
Apprenticeship model with communication
embedded within meaningful contexts

Evidence, ES, Conclusions

Script training
Approximately 15 studies
PWA have variable characteristics
Mild to moderate aphasia
Typically 6 months or more post onsets

Outcomes

Improved production of practiced scripts

Some generalization to other communication situations
Slightly increased speaking rate
Error reduction

Insufficient evidence for systematic review - yet

 Review of partner training studies

PWA variable characteristics

Most lived independently

4-178 MPO
Mild to moderate to severe aphasia
Comprehension and/or expression deficits

Partners
Primarily family members or usual partners

Approaches
Partner change was goal
Facilitate desirable behavior or inhibit undesirable behavior
Turner & Whitworth , 2006;
http://www.asha.org/members/reviews.aspx?id=7499

 Outcomes
Improved interaction
More successful conversation turns
Fewer interruptions
Fewer turns devoted to repair

Successful social validation

More accurate sense of partners aphasia
Maintenance and generalization of behavior

Turner & Whitworth, 2006

 Moderate (RCT) to limited (small studies)

evidence supporting conversation and partner
training
Considerations
Individual personalities of PWAs and partners
Conversational style

Turner & Whitworth, 2006

Treatment techniques
PACE and RET
Several studies investigating each treatment
Primarily positive results reported
Trained items
Untrained items
Generalization items

No systematic review of the techniques

Single subject design studies

 Conversational Coaching and Reciprocal

Scaffolding
Few studies investigating each treatment
Primarily positive results reported
Some generalization reported

No systematic review of the technique

Single subject design studies

Summary
Moderate (small studies) or inconsistent (RCTs) support for
group treatment.
Modest support for script training (multiple forms).

Modest support for communication partner training.

Modest support for PACE and RET.

TREATMENT INFLUENCES

Intensity and Dosage

Theories supporting treatment intensity
Hebbian cell assemblies (Hebb, 1949)
Education learning theory http://www.emtech.net/learning_theories.htm
Neuronal plasticity (Kleim & Jones, 2008)
Dosage (frequency, intensity, duration)

Early aphasia treatment research (Darley, 1972)

Activity/Participation
Impairment

ES for
Outcome
Measures for
studies
investigating
intensity of
treatment

Cherney, Patterson, Raymer, Frymark

& Schooling, 2008;
Frymark, Cherney, Patterson & Raymer, 2010

Content Units
Content Analysis
Communication Activity Log-SLPs2.64
Communication Activity Log-Patients
Catalogue order-written-quiet
Catalogue order-written-dual task
Catalogue order-oral-quiet
Catalogue order-oral-dual task
CADL-2
Word/Picture Verification-Maintenance-lo
Word/Picture Verification-Maintenance-hi
Word/Picture Verification-Acquisition-lo
Word/Picture Verification-Acquisition-hi
WAB AQ
WAB AQ
WAB AQ
WAB AQ
Picture Naming-Maintenance-lo
Picture Naming-Maintenance-hi
Picture Naming-Acquisition-lo
Picture Naming-Acquisition-hi
Naming
Naming
Naming
Naming
Naming
Naming
Naming
Fable retell-words
Fable retell-utterances
Fable retell-TTR
Fable retell-MLU
AAT Naming
AAT Langugae Comprehension
-1.2

0.8

2.8

4.8

6.8

8.8

10.8

12.8

Errorless (Reduced Error) Learning

Theoretical foundation
Initially demonstrated in animal learning
Memory rehabilitation
Error behavior can be self-reinforcing > eliminate

Contrast
Errorless learning
Error elimination
Error reduction

Errorful learning (cueing hierarchy)

Errors not controlled

 Review of 27 studies
91 outcome measures at three times
Immediate benefit = 78% yes; 25% no
Follow up benefit = 38% yes; 27% no
Generalization = 30% yes; 67% no

Variations
Aphasia type and fluency
Therapy type (expressive, receptive, mixed, nonlangugae)
Technique (Errorful, error reducing, error elimination)

Fillingham, Hodgson, Sage & Lambon Ralph (2003)

Neuronal Plasticity
Principles of experience-dependent neural plasticity
Use it or lose it

Time matters

Use it and improve it

Salience matters

Specificity
Repetition matters
Intensity matters

Age matters
Transference
Interference

Kleim & Jones, 2008; Raymer et al., 2008;

Raymer, Maher, Patterson & Cherney, 2007

 Experience-dependent neuronal plasticity is

the basis for learning and influences recovery
In the presence of treatment
Without treatment as one navigates the world

Research aimed at translation of neuroscience

to neurorehabilitation
Neuroimaging studies
Dosage
Application of principles individually and in combination

Summary
Greater intensity may be more effective than lesser intensity.
Individual variation for aphasia type, TPO and task.

Errorless, reduced error and errorful treatment techniques are

effective.
Individual variation for aphasia type, TPO and task.

Principles of neuronal plasticity positively influence treatment

effectiveness.

EMERGING TREATMENTS

Emerging treatment techniques

Pharmacotherapy
Computer-aided treatment
Repetitive Transcranial Magnetic Stimulation
(rTMS)
Transcranial Direct Current Stimulation (tDCS)
Epidural cortical stimulation

Pharmacotherapy
Drugs investigated in RCTs
Piracetam
Weak evidence in support but concern for side effects

Dextran insufficient evidence

Bifemelane - insufficient evidence
Bromocriptine - insufficient evidence
Idebenone - insufficient evidence
Piribedil - insufficient evidence
Greener, Enderby & Whurr, 2010

 Additional studies of drugs therapy in aphasia

Piracetam strong, positive evidence in favor (n=5)

Bromocriptine strong evidence against (n=4)
Levodopa moderate evidence in favor (n=1)
Amphetamines moderate evidence in favor (n=2)
Bifemelane insufficient evidence (n=1)
Dextran moderate evidence against (n=1)
Moclobemide insufficient evidence (n=1)
Donepizil moderate evidence in favor during active
treatment (n=2)
Memantine moderate evidence in favor with CILT (n=1)
Salter, Teasell, Bhogal, Zettler & Foley, 2010

Computer-based Treatment
Not so new but re-emerging technique
As primary treatment (Doesborgh, van de Sandt-Koenderman, Dippel, van
Ahrskamp, Koustall & Visch-Brink, 2004; Cherney, Halper, Holladn & Cole, 2008)

Practice of skills learned in treatment

Telehealth

Strong evidence in favor of improvement at

impairment level
Limited evidence for generalization functional
communication
Salter, Teasell, Bhogal, Zettler & Foley, 2010

Cortical stimulation
Repetitive Transcranial Magnetic Stimulation (rTMS)
How it works
Noninvasive; Cause depolarization of neurons
Place electrodes on scalp at regions of interest
R perisylvian area or RH Brocas area homologue

Induces weak electric current in rapidly changing magnetic field

Facilitates neuronal activity

Some evidence in favor

Patients with chronic nonfluent aphasia
Improvement in naming
Some improvement in spontaneous speech
Salter, Teasell, Bhogal, Zettler & Foley, 2010; Martin, Naeser, Ho, Doron, Kurland, Kaplan,
Wang, Nicholas, Baker, Alonso, Fregni & Pascual-Leone, 2009

 Transcranial Direct Current Stimulation (tDCS)

How it works
Application of weak electrical currents (1-2 mA) to
modulate the activity of neurons
Polarity determines whether excitability is increased or
decreased

Limited evidence in favor

Patients with chronic nonfluent aphasia
Improvement in naming
Salter, Teasell, Bhogal, Zettler & Foley, 2010;
Baker, Rorden & Fridriksson, 2010

 Epidural Cortical Stimulation

How it works
Impulse generator implanted subclavicularly
Epidural electrode embedded over dura of target
cortical area
Neurons stimulated; perhaps to rewire themselves

Limited evidence in favor when used with

behavioral treatment
Chronic nonfluent aphasia
Cherney, 2009; Cherney & Small, 2007

Summary
Inconsistent evidence supporting pharmacological treatment.
Some favorable evidence in conjunction with behavioral treatment.

Computer-based treatment effective at impairment level;

inconsistent evidence for generalization.
Some indication that cortical stimulation in conjunction with
behavioral treatment may improve naming.