First decade of research on constrained-induced treatment approaches for aphasia rehabilitation

High-Intensity Aphasia Therapy Is Cost-Effective in People With Poststroke Aphasia: Evidence From the COMPARE Trial

BACKGROUND

Evidence from systematic reviews confirms that speech and language interventions for people with aphasia during the chronic phase after stroke (>6 months) improve word retrieval, functional communication, and communication-related quality of life. However, there is limited evidence of their cost-effectiveness. We aimed to estimate the cost per quality-adjusted life year gained from 2 speech and language therapies compared with usual care in people with aphasia during the chronic phase (median, 2.9 years) after stroke.

METHODS

A 3-arm, randomized controlled trial compared constraint-induced aphasia therapy plus (CIAT-Plus) and multimodality aphasia therapy (M-MAT) with usual care in 216 people with chronic aphasia. Participants were administered a standardized questionnaire before intervention and at 12 weeks after the 2-week intervention/control period to ascertain health service utilization, employment changes, and informal caregiver burden. Unit prices from Australian sources were used to estimate costs in 2020. Quality-adjusted life years were estimated using responses to the EuroQol-5 Dimension-3 Level questionnaire. To test uncertainty around the differences in costs and outcomes between groups, bootstrapping was used with the cohorts resampled 1000 times.

RESULTS

Overall 201/216 participants were included (mean age, 63 years, 29% moderate or severe aphasia, 61 usual care, 70 CIAT-Plus, 70 M-MAT). There were no statistically significant differences in mean total costs ($13 797 usual care, $17 478 CIAT-Plus, $11 113 M-MAT) and quality-adjusted life years (0.19 usual care, 0.20 CIAT-Plus, 0.20 M-MAT) between groups. In bootstrapped analysis of CIAT-Plus, 21.5% of iterations were likely to result in better outcomes and be cost saving (dominant) compared with usual care. In contrast, 72.4% of iterations were more favorable for M-MAT than usual care.

CONCLUSIONS

We observed that both treatments, but especially M-MAT, may result in better outcomes at an acceptable additional cost, or potentially with cost savings. These findings are relevant in advocating for the use of these therapies for chronic aphasia after stroke.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia

BACKGROUND

While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.

METHODS

We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.

RESULTS

We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.

CONCLUSIONS

CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.

TRIAL REGISTRATION NUMBER

ACTRN 2615000618550.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Treatment of Underlying Forms: A Bayesian Meta-Analysis of the Effects of Treatment and Person-Related Variables on Treatment Response

Purpose This meta-analysis synthesizes published studies using "treatment of underlying forms" (TUF) for sentence-level deficits in people with aphasia (PWA). The study aims were to examine group-level evidence for TUF efficacy, to characterize the effects of treatment-related variables (sentence structural family and complexity; treatment dose) in relation to the Complexity Account of Treatment Efficacy (CATE) hypothesis, and to examine the effects of person-level variables (aphasia severity, sentence comprehension impairment, and time postonset of aphasia) on TUF response. Method Data from 13 single-subject, multiple-baseline TUF studies, including 46 PWA, were analyzed. Bayesian generalized linear mixed-effects interrupted time series models were used to assess the effect of treatment-related variables on probe accuracy during baseline and treatment. The moderating influence of person-level variables on TUF response was also investigated. Results The results provide group-level evidence for TUF efficacy demonstrating increased probe accuracy during treatment compared with baseline phases. Greater amounts of TUF were associated with larger increases in accuracy, with greater gains for treated than untreated sentences. The findings revealed generalization effects for sentences that were of the same family but less complex than treated sentences. Aphasia severity may moderate TUF response, with people with milder aphasia demonstrating greater gains compared with people with more severe aphasia. Sentence comprehension performance did not moderate TUF response. Greater time postonset of aphasia was associated with smaller improvements for treated sentences but not for untreated sentences. Conclusions Our results provide generalizable group-level evidence of TUF efficacy. Treatment and generalization responses were consistent with the CATE hypothesis. Model results also identified person-level moderators of TUF (aphasia severity, time postonset of aphasia) and preliminary estimates of the effects of varying amounts of TUF for treated and untreated sentences. Taken together, these findings add to the TUF evidence and may guide future TUF treatment-candidate selection. Supplemental Material https://doi.org/10.23641/asha.16828630.

Statistical analysis plan for the COMPARE trial: a 3-arm randomised controlled trial comparing the effectiveness of Constraint-induced Aphasia Therapy Plus and Multi-modality Aphasia Therapy to usual care in chronic post-stroke aphasia (COMPARE)

BACKGROUND

While high-quality meta-analyses have confirmed the effectiveness of aphasia therapy after stroke, there is limited evidence for the comparative effectiveness of different aphasia interventions. Two commonly used interventions, Constraint-induced Aphasia Therapy Plus (CIAT Plus) and Multi-modality Aphasia Therapy (M-MAT), are hypothesised to rely on diverse underlying neural mechanisms for recovery and may be differentially responsive to aphasia severity. COMPARE is a prospective randomised open-blinded end-point trial designed to determine whether, in people with chronic post-stroke aphasia living in the community, CIAT Plus and M-MAT provide greater therapeutic benefit compared to usual care, are differentially effective according to aphasia severity, and are cost-effective. This paper details the statistical analysis plan for the COMPARE trial developed prior to data analysis.

METHODS

Participants (n = 216) are randomised to one of three arms, CIAT Plus, M-MAT or usual care, and undertake therapy with a study trained speech pathologist in groups of three participants stratified by aphasia severity. Therapy occurs for 3 h blocks per day for 10 days across 2 weeks. The primary clinical outcome is aphasia severity as measured by the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ) immediately post intervention. Secondary outcomes include WAB-R-AQ at 12-week follow-up, and functional communication, discourse efficiency, multimodal communication, and health-related quality of life immediately post intervention and at 12-week follow-up.

RESULTS

Linear mixed models (LMMs) will be used to analyse differences between M-MAT and UC, and CIAT-Plus and UC on each outcome measure immediately and at 12 weeks post-intervention. The LMM for WAB-R-AQ will assess the differences in efficacy between M-MAT and CIAT-Plus. All analyses will control for baseline aphasia severity (fixed effect) and for the clustering effect of treatment groups (random effect).

DISCUSSION

This trial will provide relative effectiveness data for two common interventions for people with chronic post-stroke aphasia, and highlight possible differential effects based on aphasia severity. Together with the health economic analysis data, the results will enable more informed personalised prescription for aphasia therapy after stroke.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN 12615000618550 . Registered on 15 June 2016.

Constraint-induced aphasia therapy for patients with aphasia: A systematic review

Objectives

This study aimed to systematically evaluate the effects of constraint-induced aphasia therapy (CIAT) for aphasic patients reported by randomized controlled trials.

Methods

Relevant randomized controlled trials were retrieved from 11 electronic databases. A methodological quality assessment was conducted in accordance with the Cochrane Handbook, and meta-analyses were performed by using RevMan 5.2. A descriptive analysis was conducted when the included trials were not suitable for a meta-analysis.

Results

A total of 12 trials were included. A statistically significant group difference was shown from the meta-analysis in the results measured by the Western Aphasia Battery (random-effects model, MD = 1.23, 95% CI = 0.31 to 2.14, P < 0.01). However, there were no statistically significant differences shown in the results of the Boston Naming Test (fixed-effects model, MD = −1.79, 95% CI = −11.19 to 7.62, P > 0.05) and Aachen Aphasia Test (fixed-effects model, MD = −1.11, 95% CI = −4.49 to 2.27, P > 0.05). The descriptive analysis showed positive results in language performances of naming, repetition, and comprehension.

Conclusion

This systematic review indicated that CIAT was efficient for improving language performance with regard to naming, comprehension, repetition, written language, and oral language based on the current evidence. And this review provides some meaningful guides for clinical practice: expand the therapy duration to 2 or 3 h per day, focus on naming, and choose the best assessment tool. It also indicates a need for more rigorous, large-scale, and high-quality trials in the future.

Neuroregeneration and plasticity: a review of the physiological mechanisms for achieving functional recovery postinjury

Neuronal networks, especially those in the central nervous system (CNS), evolved to support extensive functional capabilities while ensuring stability. Several physiological "brakes" that maintain the stability of the neuronal networks in a healthy state quickly become a hinderance postinjury. These "brakes" include inhibition from the extracellular environment, intrinsic factors of neurons and the control of neuronal plasticity. There are distinct differences between the neuronal networks in the peripheral nervous system (PNS) and the CNS. Underpinning these differences is the trade-off between reduced functional capabilities with increased adaptability through the formation of new connections and new neurons. The PNS has "facilitators" that stimulate neuroregeneration and plasticity, while the CNS has "brakes" that limit them. By studying how these "facilitators" and "brakes" work and identifying the key processes and molecules involved, we can attempt to apply these theories to the neuronal networks of the CNS to increase its adaptability. The difference in adaptability between the CNS and PNS leads to a difference in neuroregenerative properties and plasticity. Plasticity ensures quick functional recovery of abilities in the short and medium term. Neuroregeneration involves synthesizing new neurons and connections, providing extra resources in the long term to replace those damaged by the injury, and achieving a lasting functional recovery. Therefore, by understanding the factors that affect neuroregeneration and plasticity, we can combine their advantages and develop rehabilitation techniques. Rehabilitation training methods, coordinated with pharmacological interventions and/or electrical stimulation, contributes to a precise, holistic treatment plan that achieves functional recovery from nervous system injuries. Furthermore, these techniques are not limited to limb movement, as other functions lost as a result of brain injury, such as speech, can also be recovered with an appropriate training program.

Follow-Up in Aphasia Caused by Acute Stroke in a Prospective, Randomized, Clinical, and Experimental Controlled Noninvasive Study With an iPad-Based App (Neolexon®): Study Protocol of the Lexi Study

Rationale: Treatment of aphasia is still challenging for clinicians and patients. So far, there is proven evidence for "face-to-face" speech therapy. However, the digital age potentially offers new and complementary strategies that may add to treatment outcome in a cost-effective way. Neolexon® is a commercial tablet-based software for treatment of aphasia, which can be applied with the help of a therapist or as self-training by the patient. Aims and hypothesis: In the Lexi study, we aim to determine whether treatment with Neolexon® is superior to standard therapy in acute post-stroke aphasia. Sample size estimates: A sample size of 180 patients, 90 for each group, will be included with an assumed dropout rate of ~20%. Methods and design: Prospective, randomized, parallel group, open-label, blinded-endpoint clinical, and experimental controlled non-invasive trial (PROBE). Adult German native speakers with acute aphasia after stroke are included. Computer-generated, blocked, and stratified randomization by aphasia severity will assign patients to one of two groups: 4 weeks of either standard logopedic speech therapy or logopedic speech therapy with the app version of Neolexon®. Both groups will be instructed in self-training: the frequency and duration of self-training will be documented. Screening for aphasia will be performed using the Language Screening Test (LAST). The severity of aphasia in general and in subitems will be assessed using the Bielefelder Aphasie Screening (BIAS) and the Aphasia Check List (ACL). Follow-up will be assessed after 3 months. Study outcomes: Based on the consensus in our study team, we considered a 10% mean difference in the change of percentile rank (PR) of BIAS to be a minimal and clinically important difference. The primary endpoint is defined as a significant difference in BIAS comparing the two groups. Differences in quality of life, Beck Depression Inventory (BDI), and modified Ranking Scale (mRS) will be evaluated as secondary outcome parameters. Discussion: This trial will determine whether speech therapy with the use of Neolexon® is superior to standard logopedic therapy. Subgroups with the greatest response to Neolexon® will be described. The trial was prospectively registered on the "EU Clinical Trials Register" (NCT04080817).

Constraint-induced or multi-modal personalized aphasia rehabilitation (COMPARE): A randomized controlled trial for stroke-related chronic aphasia

RATIONALE

The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown.

AIMS AND HYPOTHESES

In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia.

SAMPLE SIZE ESTIMATES

A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05.

METHODS AND DESIGN

Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care).

STUDY OUTCOMES

WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks.

DISCUSSION

This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

Combining rTMS With Intensive Language-Action Therapy in Chronic Aphasia: A Randomized Controlled Trial

Neuromodulation technologies, such as transcranial magnetic stimulation (TMS), are promising tools for neurorehabilitation, aphasia therapy included, but not yet in common clinical use. Combined with behavioral techniques, in particular treatment-efficient Intensive Language-Action Therapy (ILAT, previously CIAT or CILT), TMS could substantially amplify the beneficial effect of such behavioral therapy alone (Thiel et al., 2013; Martin et al., 2014; Mendoza et al., 2016; Kapoor, 2017). In this randomized study of 17 subjects with post-stroke aphasia in the chronic stage, we studied the combined effect of ILAT and 1-Hz placebo-controlled navigated repetitive TMS (rTMS) to the right-hemispheric inferior frontal cortex—that is, to the anterior part of the non-dominant hemisphere's homolog Broca's area (pars triangularis). Patients were randomized to groups A and B. Patients in group A received a 2-week period of rTMS during naming training where they named pictures displayed on the screen once every 10 s, followed by 2 weeks of rTMS and naming combined with ILAT. Patients in group B received the same behavioral therapy but TMS was replaced by sham stimulation. The primary outcome measures for changes in language performance were the Western Aphasia Battery's aphasia quotient AQ; the secondary outcome measures were the Boston naming test (BNT) and the Action naming test (Action BNT, ANT). All subjects completed the study. At baseline, no statistically significant group differences were discovered for age, post-stroke time or diagnosis. ILAT was associated with significant improvement across groups, as documented by both primary and secondary outcome measures. No significant effect of rTMS could be documented. Our results agree with previous results proving ILAT's ability to improve language in patients with chronic aphasia. In contrast with earlier claims, however, a beneficial effect of rTMS in chronic post-stroke aphasia rehabilitation was not detected in this study.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03629665

Neuroimaging of stroke recovery from aphasia - Insights into plasticity of the human language network

The role of left and right hemisphere brain regions in language recovery after stroke-induced aphasia remains controversial. Here, we summarize how neuroimaging studies increase the current understanding of functional interactions, reorganization and plasticity in the language network. We first discuss the temporal dynamics across the time course of language recovery, with a main focus on longitudinal studies from the acute to the chronic phase after stroke. These studies show that the functional contribution of perilesional and spared left hemisphere as well as contralesional right hemisphere regions to language recovery changes over time. The second section introduces critical variables and recent advances on early prediction of subsequent outcome. In the third section, we outline how multi-method approaches that combine neuroimaging techniques with non-invasive brain stimulation elucidate mechanisms of plasticity and reorganization in the language network. These approaches provide novel insights into general mechanisms of plasticity in the language network and might ultimately support recovery processes during speech and language therapy. Finally, the neurobiological correlates of therapy-induced plasticity are discussed. We argue that future studies should integrate individualized approaches that might vary the combination of language therapy with specific non-invasive brain stimulation protocols across the time course of recovery. The way forward will include the combination of such approaches with large data sets obtained from multicentre studies.

Aphasia As a Predictor of Stroke Outcome

PURPOSE OF REVIEW

Aphasia is a common feature of stroke, affecting 21-38% of acute stroke patients and an estimated 1 million stroke survivors. Although stroke, as a syndrome, is the leading cause of disability in the USA, less is known about the independent impact of aphasia on stroke outcomes.

RECENT FINDINGS

During the acute stroke period, aphasia has been found to increase length of stay, inpatient complications, overall neurological disability, mortality, and to alter discharge disposition. Outcomes during the sub-acute and chronic stroke periods show that aphasia is associated with lower Functional Independence Measures (FIM) scores, longer stays in rehabilitation settings, poorer function in activities of daily living, and mortality. Factors that complicate the analysis of aphasia on post-stroke outcomes, however, include widely different systems of care across international settings that result in varying admission patterns to acute stroke units, allowable length of stays based on reimbursement, and criteria for rehabilitation placement. Aphasia arising from stroke is associated with worse outcomes both in the acute and chronic periods. Future research will have to incorporate disparate patterns in analytic models, and to take into account specific aphasia profiles and evolving methods of post-stroke speech-language therapy.

Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Constraint-induced aphasia therapy (CIAT) has been widely used in post-stroke aphasia rehabilitation. An increasing number of clinical controlled trials have investigated the efficacy of the CIAT for the post-stroke aphasia.

PURPOSE

To systematically review the randomized controlled trials (RCTs) concerning the effect of the CIAT in post-stroke patients with aphasia, and to identify the useful components of CIAT in post-stroke aphasia rehabilitation.

METHODS

A computerized database search was performed through five databases (Pubmed, EMbase, Medline, ScienceDirect and Cochrane library). Cochrane handbook domains were used to evaluate the methodological quality of the included RCTs.

RESULTS

Eight RCTs qualified in the inclusion criteria. Inconsistent results were found in comparing the CIAT with conventional therapies without any component from the CIAT based on the results of three RCTs. Five RCTs showed that the CIAT performed equally well as other intensive aphasia therapies, in terms of improving language performance. One RCT showed that therapies embedded with social interaction were likely to enhance the efficacy of the CIAT.

CONCLUSION

CIAT may be useful for improving chronic post-stroke aphasia, however, limited evidence to support its superiority to other aphasia therapies. Massed practice is likely to be a useful component of CIAT, while the role of "constraint" is needed to be further explored. CIAT embedded with social interaction may gain more benefits.

The feasibility of delivering constraint-induced language therapy via the Internet

Objective

This study is designed to determine the feasibility of the provision of an evidenced-based aphasia therapy, constraint-induced language therapy, via telerehabilitation. It describes the computer software that was developed specifically for the delivery of constraint-induced language therapy in the online environment and presents two case studies.

Methods

Two participants with chronic aphasia were assessed before and after a two-week intensive treatment block of constraint-induced language therapy delivered via Web-based videoconferencing. The group-based, dual card request game utilized in face-to-face constraint-induced language therapy was transformed into an innovative and user-friendly Web-based game - Internet constraint-induced language therapy (iCILT). Participants accessed iCILT via the Internet from their own home every weekday for two weeks. Language and quality of life measures were administered pre- and post-therapy in order to detect treatment effects. Participant satisfaction information was also recorded.

Results

Online delivery of iCILT was technically feasible and participant satisfaction was high with a number of benefits associated with telerehabilitation identified by participants. Post-treatment performance for language functioning and communication-related quality of life was variable for each participant, however improvements in naming were noted.

Conclusions

Constraint-induced language therapy delivered via telerehabilitation may be a feasible alternative to traditional face-to-face therapy for people with chronic aphasia.

Constraint Induced Aphasia Therapy: Volunteer-led, unconstrained and less intense delivery can be effective

BACKGROUND

Constraint Induced Aphasia Therapy (CIAT) has been shown to be effective in the treatment of aphasia, but clinicians have expressed concern regarding how far CIAT is practical to implement in clinical practice.

OBJECTIVE

To determine whether CIAT delivered in a less-intense, lower dose, reduced constraint and volunteer-led format could produce positive outcomes in people with chronic aphasia.

METHODS

Two groups were run, each with two people with chronic aphasia. Treatment involved a standard CIAT card-exchange game, supplemented by a home activity. Spoken language was required for responses but alternative modalities of communication were also permitted. Each group was led by a trained volunteer, lasted 90 minutes and was delivered twice a week for four weeks.

RESULTS

Three of the four participants showed significant improvements in target word retrieval following treatment. No significant improvements were observed for untreated stimuli or language tasks. Two participants showed increases in the elaboration of their responses, and the same two showed an increase in the frequency with which they engaged in communication activities.

CONCLUSIONS

Clear gains in performance were observed for the majority of people with aphasia who participated in a less intense format, considerably lower dose and less constrained form of CIAT led by trained volunteers. This suggests that this 'clinically realistic' service delivery model for CIAT could be added to the clinical repertoire of speech pathologists.

Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint

Purpose

Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical.

Method

Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality.

Results

All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant.

Conclusion

Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Collaborative participation in aphasic conversation before and after intensive language-action therapy

This study applies conversation analysis to compare everyday conversation samples between a person with aphasia (PWA) and a familiar communication partner (CP) before and after intensive language-action therapy (ILAT). Our analysis concentrated on collaborative repair sequences with the assumption that impairment-focused therapy would translate into a change in the nature of trouble sources, which engender collaborative repair action typical of aphasic conversation. The most frequent repair initiation technique used by the CP was candidate understandings. The function of candidate understandings changed from addressing specific trouble sources pre-ILAT to concluding longer stretches of the PWA's talk post-ILAT. Alongside with these findings, we documented a clinically significant increase in the Western Aphasia Battery's aphasia quotient post-ILAT. Our results suggest that instead of mere frequency count of conversational behaviours, examining the type and function of repair actions might provide insight into therapy-related changes in conversation following impairment-focused therapy.

Tyranny of the randomised clinical trial

Researchers and clinicians often disagree about what it means to provide the best possible care. This paper's purpose is to propose ways of resolving the disagreements. The first is to have both groups re-examine the three equal components of evidence-based practice, a re-examination that begins with rejection of the randomised clinical trial's tyranny. The second is for researchers to design rehabilitation research based on a biopsychosocial rather than a biomedical model. The third is for both groups to redefine translational research so that it means both translation from the laboratory to the clinic and from the clinic to the laboratory. The fourth is to advocate for a science of dissemination that is as robust as rehabilitation's present science of discovery. Most examples are drawn from the literature on acquired neurologic speech and language disorders.

Increasing aphasia treatment intensity in an acute inpatient rehabilitation program: A feasibility study

BACKGROUND

Intensity of therapy is a critical factor influencing outcomes in aphasia. However, there are many barriers to increasing treatment intensity for those with acute/subacute aphasia including the demands of the inpatient medical facilities and the endurance of the participants. Nevertheless, with some modifications to its original procedures, evidence suggests that Constraint Induced Language Therapy (CILT) may yield positive outcomes when given in the early stages of recovery.

AIMS

To investigate the feasibility of increasing the amount of therapy provided to individuals with aphasia on an inpatient rehabilitation unit by adding CILT at a modified intensity, and to assess whether those receiving two weeks of the additional CILT show more improvement than control participants who did not receive the additional treatment.

METHODS AND PROCEDURES

A case-series single-subject design study was conducted. All participants received usual care of approximately an hour of speech and language treatment, five to six days a week. Participants in the experimental condition received an additional hour-long CILT session, five days per week, for two weeks. Trained, untrained, and generalization probes comprising naming of pictured items and oral reading of sentences were taken at baseline, during treatment, and at post-treatment. All participants were probed equally. Probe performance was scored and effect sizes were calculated and compared. Performance gains from pre- to post-treatment on subtests of the Boston Diagnostic Aphasia Examination were also compared.

OUTCOMES AND RESULTS

Thirteen individuals with aphasia onset ranging from 7 to 68 days were recruited, with 6 allocated to the experimental Usual Care + CILT condition and 7 allocated to the control Usual Care condition. Increasing the amount of speech and language therapy by adding an hour of daily CILT was feasible. Individual performance varied within and across conditions with large gains noted in some, but not all participants. As a group, there was a small to medium effect size of the Usual Care + CILT condition over Usual Care alone for trained and untrained oral reading probes and untrained naming probes.

CONCLUSIONS

It is feasible to increase the amount of treatment provided to participants with aphasia on an acute inpatient rehabilitation unit. Preliminary results suggest that there may be better outcomes for those who receive more treatment. Further research using larger numbers of homogeneous participants and controlling for content of therapy as well as amount of therapy is warranted.

Constraint-induced aphasia therapy versus intensive semantic treatment in fluent aphasia

OBJECTIVE

The authors compared the effectiveness of 2 intensive therapy methods: Constraint-Induced Aphasia Therapy (CIAT; Pulvermüller et al., 2001) and semantic therapy (BOX; Visch-Brink & Bajema, 2001).

METHOD

Nine patients with chronic fluent aphasia participated in a therapy program to establish behavioral treatment outcomes. Participants were randomly assigned to one of two groups (CIAT or BOX).

RESULTS

Intensive therapy significantly improved verbal communication. However, BOX treatment showed a more pronounced improvement on two communication-namely, a standardized assessment for verbal communication, the Amsterdam Nijmegen Everyday Language Test (Blomert, Koster, & Kean, 1995), and a subjective rating scale, the Communicative Effectiveness Index (Lomas et al., 1989). All participants significantly improved on one (or more) subtests of the Aachen Aphasia Test (Graetz, de Bleser, & Willmes, 1992), an impairment-focused assessment. There was a treatment-specific effect. BOX treatment had a significant effect on language comprehension and semantics, whereas CIAT treatment affected language production and phonology.

CONCLUSION

The findings indicate that in patients with fluent aphasia, (a) intensive treatment has a significant effect on language and verbal communication, (b) intensive therapy results in selective treatment effects, and (c) an intensive semantic treatment shows a more striking mean improvement on verbal communication in comparison with communication-based CIAT treatment.

Action observation as a tool for neurorehabilitation to moderate motor deficits and aphasia following stroke

The mirror neuron system consists of a set of brain areas capable of matching action observation with action execution. One core feature of the mirror neuron system is the activation of motor areas by action observation alone. This unique capacity of the mirror neuron system to match action perception and action execution stimulated the idea that mirror neuron system plays a crucial role in the understanding of the content of observed actions and may participate in procedural learning. These features bear a high potential for neurorehabilitation of motor deficits and of aphasia following stroke. Since the first articles exploring this principle were published, a growing number of follow-up studies have been conducted in the last decade. Though, the combination of action observation with practice of the observed actions seems to constitute the most powerful approach. In the present review, we present the existing studies analyzing the effects of this neurorehabilitative approach in clinical settings especially in the rehabilitation of stroke associated motor deficits and give a perspective on the ongoing trials by our research group. The data obtained up to date showed significant positive effect of action observation on recovery of motor functions of the upper limbs even in the chronic state after stroke, indicating that our approach might become a new standardized add-on feature of modern neurorehabilitative treatment schemes.

Using informative verbal exchanges to promote verb retrieval in nonfluent aphasia

PURPOSE

The goal of this study was to determine whether positive treatment effects of a modified constraint-induced language therapy focused on verb production would generalize to unpracticed items and tasks.

METHOD

Four individuals participated in a single-subject treatment design protocol. The treatment involved intensive practice producing verbs in sentences in an informative communicative exchange. Direct treatment outcome was examined by measuring the accuracy of producing practiced verbs in an action description task, a task similar to those used in treatment. Generalization was assessed by measuring production of unpracticed verbs and sentence grammaticality in the action description task and by measuring verb production and sentence grammaticality in 2 relatively unstructured (unpracticed) language tasks.

RESULTS

Two of the 4 participants showed a direct treatment effect, producing a greater number of practiced verbs in the action description task following treatment compared with before treatment. All participants improved sentence grammaticality following treatment, although grammaticality was not explicitly targeted in therapy. Generalization to unpracticed, less-structured tasks was variable across the participants.

CONCLUSION

Patterns of generalization may depend on participants' specific language deficits and production characteristics, on the language tasks used, and on the measures used to detect change and assess generalization.

A Single-subject Study to Examine the Effects of Constrained-induced Aphasia Therapy on Naming Deficit

Aphasia is prevalent in people following stroke, which can have a significant impact on the quality of life of the patients with stroke. One of the new methods for treatment of patients with aphasia is constraint-induced aphasia therapy (CIAT). The aim of this study was to investigate the efficacy of CIAT on naming deficits in individuals with chronic aphasia. This study had a prospective, single-subject study with A-B-A design. The CIAT was administered to two patients with chronic aphasia. Participants were a 57-year-old male and a 45-year-old female and had a stroke 60 and 36 months ago, respectively. In this study, the naming test was used as the outcome measure. The naming test was administered in three baseline sessions with 1 week interval between tests (phase A). Patients received CIAT for four consecutive weeks (3 days/week). Four measurements were taken during the treatment phase (phase B). In follow-up phase (phase A) two other measurements were performed. Visual analysis consisting of level, regression line, and variability were used to determine the effects of CIAT on naming. Both participants increased scores on naming test after phase A and B. The mean of the naming score improved from the baseline to the intervention phase in both participants. There was a positive trend in naming scores during the treatment phase compared with the trend in the baseline demonstrated by both participants. The results of this study showed that the CIAT can be effective in improving the naming deficit in patients with chronic post-stroke aphasia.

Dosing of a cued picture-naming treatment for anomia

PURPOSE

Recent investigations into effects of intensity or distribution of aphasia therapy have provided moderate evidence supporting intensive therapy schedules on aphasia treatment response. The purpose of the present study was to investigate the feasibility of creating an intensive therapy session without extending the amount of daily time a person spends in treatment.

METHOD

Individuals who presented with chronic anomia poststroke (N = 8) participated in 2 weeks of a computerized, therapist-delivered, cued, picture-naming treatment. Dosing parameters for each session were 8 presentations of 50 pictures, totaling 400 teaching episodes per session.

RESULTS

Of the 8 participants, 6 achieved significant increases from baseline on trained items after 400 teaching episodes (i.e., 1 treatment hr), and the remaining 2 participants achieved significant increases from baseline after 1200 teaching episodes (i.e., 3 treatment hr). Maintenance data from 7 of the participants indicated that 6 participants maintained significant improvement from baseline on trained items.

CONCLUSIONS

Given an intensive and saturated context, anomic individuals were surprisingly quick at relearning to produce problematic words successfully. Most participants demonstrated retention of the gains 2 months after treatment ended. The high density of teaching episodes within the treatment session (i.e., the intensive treatment schedule) may have contributed to the behavioral gains.

An enhanced protocol for constraint-induced aphasia therapy II: a case series

PURPOSE

The initial version of Constraint-Induced Aphasia Therapy (CIAT I) consisted of a single exercise. This study sought to evaluate the feasibility for future trials of an expanded and restructured protocol designed to increase the efficacy of CIAT I.

METHOD

The subjects were 4 native English speakers with chronic stroke who exhibited characteristics of moderate Broca's aphasia. Treatment was carried out for 3.5 hr/day for 15 consecutive weekdays. It consisted of 3 components: (a) intensive training by a behavioral method termed shaping using a number of expressive language exercises in addition to the single original language card game, (b) strong discouragement of attempts to use gesture or other nonverbal means of communication, and (c) a transfer package of behavioral techniques to promote transfer of treatment gains from the laboratory to real-life situations.

RESULTS

Participation in speech in the life situation improved significantly after treatment. The effect sizes (i.e., d') in this domain were ≥ 2.2; d' values ≥ 0.8 are considered large. Improvement in language ability on a laboratory test, the Western Aphasia Battery-Revised (Kertesz, 2006), did not achieve statistical significance, although the effect size was large--that is, 1.3 (13.1 points).

CONCLUSION

These pilot results suggest in preliminary fashion that CIAT II may produce significant improvements in everyday speech.

Language improvements after TMS plus modified CILT: Pilot, open-protocol study with two, chronic nonfluent aphasia cases

PURPOSE

The purpose of this study was to investigate: 1) the feasibilty of administering a modified CILT (mCILT) treatment session immediately after TMS; and 2) if this combined therapy could improve naming and elicited propositional speech in chronic, nonfluent aphasia.

METHODS

Two chronic stroke patients with nonfluent aphasia (mild-moderate and severe) each received twenty minutes of rTMS to suppress the right pars triangularis, followed immediately by three hours of mCILT (5 days/week, 2 weeks). (Each patient had received TMS alone, 2-6 years prior.) Language evaluations were performed pre- TMS+mCILT, and post- at 1-2 months, and 6 or 16 months.

RESULTS

Both patients showed significant improvements in naming pictures, and elicited propositional speech at 1-2 months post- TMS+mCILT. The improved naming was still present at 6 months post- TMS+mCILT for P2; but not at 16 months post- TMS+mCILT for P1.

CONCLUSIONS

It is feasible to administer mCILT for three hours immediately after a TMS session. It is unknown if the significant improvements in naming pictures, and elicited propositional speech were associated with the second series of TMS, or this first series of mCILT, or a combination of both. A larger, sham controlled clinical trial is warranted.

A randomized, rater-blinded, parallel trial of intensive speech therapy in sub-acute post-stroke aphasia: the SP-I-R-IT study

BACKGROUND

There is conflicting evidence regarding the benefits of intensive speech and language therapy (SLT), particularly because intensity is often confounded with total SLT provided.

AIMS

A two-centre, randomized, rater-blinded, parallel study was conducted to compare the efficacy of 100 h of SLT in a regular (RT) versus intensive (IT) treatment in sub-acute post-stroke aphasia.

METHODS & PROCEDURES

Consecutive patients with aphasia, within 3 months of a left hemisphere ischemic stroke, were randomized to IT (2 h per day × 5 days per week, 10 weeks) or RT (2 h per week × 50 weeks). Evaluations took place at 10, 50 and 62 weeks. Primary outcome was the frequency of responders, defined by 15% increase of Aphasia Quotient (AQ) from the baseline to 50 weeks. Secondary outcomes were changes from the baseline in AQ and functional communication profile (FCP) at 50 and 62 weeks and improvement stability between 50 and 62 weeks.

OUTCOMES & RESULTS

Thirty patients were randomized and 18 completed the study. No significant differences were found between groups in primary or secondary outcomes, although IT patients (N = 9) obtained higher scores in language measures between 10 and 62 weeks in per protocol analysis. The number of non-completions was identical between groups.

CONCLUSIONS & IMPLICATIONS

This study suggests that, in the sub-acute period following stroke and controlling for the number of hours of SLT provided, there is a trend for a greater improvement in language and functional communication measures with IT compared with RT. The lack of statistical significance in results was probably due to the small sample size.

Stroke, cognitive deficits, and rehabilitation: still an incomplete picture

Cognitive impairment after stroke is common and can cause disability with major impacts on quality of life and independence. There are also indirect effects of cognitive impairment on functional recovery after stroke through reduced participation in rehabilitation and poor adherence to treatment guidelines. In this article, we attempt to establish the following: ● whether there is a distinct profile of cognitive impairment after stroke; ● whether the type of cognitive deficit can be associated with the features of stroke-related damage; and ● whether interventions can improve poststroke cognitive performance. There is not a consistent profile of cognitive deficits in stroke, though slowed information processing and executive dysfunction tend to predominate. Our understanding of structure-function relationships has been advanced using imaging techniques such as lesion mapping and will be further enhanced through better characterization of damage to functional networks and identification of subtle white matter abnormalities. Effective cognitive rehabilitation approaches have been reported for focal cortical deficits such as neglect and aphasia, but treatments for more diffusely represented cognitive impairment remain elusive. In the future, the hope is that different techniques that have been shown to promote neural plasticity (e.g., exercise, brain stimulation, and pharmacological agents) can be applied to improve the cognitive function of stroke survivors.

New evidence for therapies in stroke rehabilitation

Neurologic rehabilitation aims to reduce impairments and disabilities so that persons with serious stroke can return to participation in usual self-care and daily activities as independently as feasible. New strategies to enhance recovery draw from a growing understanding of how types of training, progressive task-related practice of skills, exercise for strengthening and fitness, neurostimulation, and drug and biological manipulations can induce adaptations at multiple levels of the nervous system. Recent clinical trials provide evidence for a range of new interventions to manage walking, reach and grasp, aphasia, visual field loss, and hemi-inattention.

Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up

OBJECTIVE

To evaluate in a preliminary manner the feasibility, safety, and efficacy of Constraint-Induced Movement therapy (CIMT) of persons with impaired lower extremity use from multiple sclerosis (MS).

DESIGN

Clinical trial with periodic follow-up for up to 4 years.

SETTING

University-based rehabilitation research laboratory.

PARTICIPANTS

A referred sample of ambulatory adults with chronic MS (N=4) with at least moderate loss of lower extremity use (average item score ≤6.5/10 on the functional performance measure of the Lower Extremity Motor Activity Log [LE-MAL]).

INTERVENTIONS

CIMT was administered for 52.5 hours over 3 consecutive weeks (15 consecutive weekdays) to each patient.

MAIN OUTCOME MEASURES

The primary outcome was the LE-MAL score at posttreatment. Secondary outcomes were posttreatment scores on laboratory assessments of maximal lower extremity movement ability.

RESULTS

All the patients improved substantially at posttreatment on the LE-MAL, with smaller improvements on the laboratory motor measures. Scores on the LE-MAL continued to improve for 6 months afterward. By 1 year, patients remained on average at posttreatment levels. At 4 years, half of the patients remained above pretreatment levels. There were no adverse events, and fatigue ratings were not significantly changed by the end of treatment.

CONCLUSIONS

This initial trial of lower extremity CIMT for MS indicates that the treatment can be safely administered, is well tolerated, and produces substantially improved real-world lower extremity use for as long as 4 years afterward. Further trials are needed to determine the consistency of these findings.

Aphasia treatment: intensity, dose parameters, and script training

Studies of aphasia treatment have shown that intensive speech-language therapy is associated with significant improvements. However, there is no standard definition of intensity and the simplistic notion that "more is better" is not necessarily supported by the research. First, current evidence regarding intensity and aphasia treatment was briefly summarized. Second, studies that directly compare conditions of higher- and lower-intensity treatment for aphasia were reviewed with regard to the inclusion of parameters that contribute to a definition of intensity. In addition to five parameters proposed by Warren, Fey, and Yoder (2007) and highlighted by Baker (2012) , total number of sessions was also often documented. The review illustrated the complexity of quantifying the dose of comprehensive treatments that target multiple modalities and utilize a variety of different strategies. Third, data from a study reporting a relationship between intensive computer-based script training and outcomes in aphasia were examined. Results serve to illustrate Baker's contention that intensity alone is insufficient without also considering the active ingredients of the teaching episode. Information about dose, therapeutic inputs, and client acts can lead to better optimization of an intervention.

Recovery of aphasia after stroke: a 1-year follow-up study

Semantics, phonology, and syntax are essential elements of aphasia diagnosis and treatment. Until now, these linguistic components have not been specifically addressed in follow-up studies of aphasia recovery after stroke. The aim of this observational prospective follow-up study was to investigate semantic, phonological, and syntactic recovery in aphasic stroke patients. In addition, we investigated the recovery of verbal communication and of aphasia severity. We assessed 147 aphasic patients at 1, 2, and 6 weeks, 3 and 6 months, and 1 year after stroke with the ScreeLing, a screening test for detecting deficits on the three main linguistic components, the aphasia severity rating scale (ASRS), a measure of verbal communication, and the Token test, a measure of aphasia severity. We investigated the differences in scores between the six time points with mixed models. Semantics and syntax improved up to 6 weeks (p < 0.001) after stroke, and phonology up to 3 months (p ≤ 0.001). ASRS improved up to 6 months (p < 0.05) and the Token test up to 3 months (p < 0.001). We conclude that in aphasia after stroke, various linguistic components have a different recovery pattern, with phonology showing the longest period of recovery that paralleled aphasia severity, as measured with the Token test. The improvement of verbal communication continues after the stabilization of the recovery of the linguistic components.