Transcript clinical bottom line

Janine Mullay and Claire Layfield (Group Co-Leaders)
Lyndsey Nickels - Academic Member
Does Constraint Induced Therapy
Improve Communication
Outcomes in People with
Aphasia?
 Originated
from CI movement therapy used
by Physios and Occupational Therapists
 Removes
compensatory strategies
 Requires
the use of verbal output
 Intensive
over short period of time
 Conducted
within small group settings
 Effectiveness
of CILT was reviewed in 2006
EBP Language group
 Topic has generated more research and
discussion since 2006
 Results from 2006 EBP review were
inconclusive
 Aim of 2010 EBP group was to (i) evaluate
new evidence (ii) provide a resource for EBP
website for SP access
 Selection
criteria = treatment effects of
CILT, aphasia post stroke and chronic
aphasia (> 6 months post stroke)
 12
 10
possible articles were found
out of 12 answered our clinical
question and were included in the CAT
 Overall
results indicate that CILT leads to
improved language outcomes
 9/10
studies reported significantly improved
language outcomes on standardised measures
 1/10
demonstrated a trend indicating
improved outcomes without statistical
significance
 Although
results typically indicated that CILT
lead to improved language outcomes only a
few studies investigated generalised
language outcomes
 Modified versions targeting generalisation
and agrammatism
 What
is the mechanism behind the
improvements???
 Constraint vs intensive other treatments

Cherney, LR, Patterson,JP, RAymer, A, Frymark,T,
Schooling, T. (2008). Evidence based 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(5):1282-1299.

CLINICAL BOTTOM LINE: Although moderate evidence exists
for more intensive treatment and CILT for individuals with
stroke induced aphasia, the results of this systematic
review should be interpreted conservatively and used in
conjunction with clinical expertise and clients’ values.

Pulvermuller, F; Neininger, B; Elbert, T; Mohr, B; Rockstroh,
B; Koebbel, P; Taub, E (2001) Constraint-induced therapy
of chronic aphasia after stroke. In Stroke, Vol 32; pp.
1621-1626.

CLINICAL BOTTOM LINE: Massed-practice constraint
induced therapy performed intensely over a short period of
time with patients with chronic aphasia resulted in
improved performance on standardised
assessment/questionnaire. In comparing with
“conventional” therapy, it is difficult to conclude whether
constraint induced therapy was more effective as the
treatments were not administered in the same frequency.

Meinzer M. Djundja D. Barthel G. Elbert T. Rockstroh B.
Long-term stability of improved language functions in
chronic aphasia after constraint-induced aphasia therapy.
Stroke. 36(7):1464-6, 2005 Jul.

CLINICAL BOTTOM LINE: Massed-practice constraintinduced therapy performed intensely over a short period of
time with patients with chronic aphasia resulted in
improved performance on standardised assessment and
questionnaires regarding quantity/quality of
communication. Unable to assess effectiveness from other
more conventional therapies

Faroqi-Shah Y, Virion CR (2009) Constraint-induced
language therapy for aggrammaticality constraints.
Aphasiology. 23 (7-8); 977-88.

CLINICAL BOTTOM LINE: Constraint induced language
therapy (with or without grammatical shaping) may lead to
improved performance in therapy tasks for patients with
Broca’s Aphasia, but may not lead to improvement in
overall language severity measures or in conversational &
narrative speech samples.

Maher, L., Kendall, D., Swearengin, J., Rodriguez, A.,
Leon, S., Pingel, K., Holland, A., & Gonsalez Rothi, L.
(2006). A pilot study of use-dependent learning in the
context of Constraint Induced Language Therapy. Journal
of the International Neuropsychological Society, 12 (1),
843-852.

CLINICAL BOTTOM LINE: Constraint induced language
therapy can improve communication outcomes based on
measures of the WAB (Aphasia Quotient), Boston Naming
Test, Action Naming Test and narrative discourse, in people
with Aphasia. However, there were nil significant
differences between CILT and PACE therapy.

Meinzer, M., Streiftau, S., & Rockstroh, B. (2007). Intensive
language training in the rehabilitation of chronic aphasia:
Efficient training by laypersons. Journal of the
International Neuropsychological Society, 13(5), 846-853.

CLINICAL BOTTOM LINE: CIAT resulted in positive language
outcomes for all individuals with chronic aphasia and can
be administered by trained laypersons with results
comparable to that of experienced therapists.

Virion, C. R. (2008). “Go aphasia!”: Examining the efficacy
of constraint-induced language therapy for individuals
with agrammatic aphasia (Master’s Thesis). Available from
Digital Repository at the University of Maryland. (Identifier
No. 8611).

CLINICAL BOTTOM LINE: Constraint induced therapy may
not improve language outcomes for people with
agrammatic aphasia. Modifying constraint induced therapy
in its original form to include a grammatical constraint
may increase its efficacy in this population.

Goral M & Kempler D (2009). Training verb production in
communicative context: Evidence from a person with
chronic non-fluent aphasia. Aphasiology, 23 (12), 13831397.

CLINICAL BOTTOM LINE: Constraint Induced Language
Therapy for the verbal production of verbs is successful in
a person with chronic non-fluent aphasia, and improves
perceptions of one’s communicative competence overall.

Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM,
Neils-Strunjas J, Newmeyer A, Reichhardt R. (2008)
Constraint Induced Aphasia Therapy stimulates language
recovery in patients with chronic aphasia after ischemic
stroke. Medical Science Monitor, 14 (5) 243 – 250.

CLINICAL BOTTOM LINE: A customised, intensive (1
week), structured Constraint Induced Aphasia Therapy
approach may improve listening skills and story retell
ability

Breier, J.I. Juranek, L. M. Maher, S. Schmadeke, D. Men, A. C.
Papanicololaou (2009). Behavioural and Neurophysiologic
Response to Therapy for Chronic Aphasia. Arch Phys Med
Rehabilitation. 90:2026-33.

CLINICAL BOTTOM LINE: Although the Right hemisphere may
support recovery of language function in response to CILT, this
recovery may not be stable and some participation of perilesional
areas of the left hemisphere may be necessary for a stable
behaviour response

Amanda Osbourne presented results from the
CILT group she ran in 2010 at the Aphasiology
Symposium

Clients were recruited from two different
metropolitan outpatient speech pathology
services – one group was conducted at each site

Clients were referred to the group as they had
ongoing aphasia of varying degrees however had
plateaued in traditional naming therapy.

They had all had inpatient rehabilitation and at
least one block of traditional outpatient therapy.

Group A ran for 1 ½ hours twice a week for 4 weeks. Total of
12 hours of therapy

2 participants

Go-fish game
 16x2 picture cards (2 sets of these)
 Barriers were used
 Clients had to explicitly address one of the players
 Pointing, gesturing, writing and drawing was not permitted
– these were the constraints
 Clients had to name the pictures (normally about 40
attempts each session)
 As the client improved they had to attempt to use
sentences to ask for the pictures
Client
Boston Naming Test pre
score (% Correct –
scores out of 60)
Boston Naming Test
post score (% correct)
EB
2 (3%)
8 (13%)
JJ
8 (13%)
18 (30%)
Client
Communication
Effectiveness Index pre
score
Communication
Effectiveness Index post
score
EB
47
43.5
JJ
32
27
Client
Modified
Communication
Effectiveness Index pre
score
Modified
Communication
Effectiveness Index post
score
EB
57
56
JJ
55
55
Client
Communication Activity
Log pre score
Communication Activity
Log post score
EB
35
48
JJ
34
30




Group ran for 1 ½ hours twice a week for 4 weeks (intensive)
Total of 12 hours
3 participants
Go-fish game –
 16x2 picture cards (3 sets of these)
 used barriers
 clients had to explicitly address one of the players
 pointing, gesturing, writing and drawing was not permitted
 had to name the pictures (normally about 30-40 attempts each
session)
 Had to put the words into whole sentences as they improved
CIAT plus – additional exercises performed each day using
constraints in everyday conversation e.g. buy bread or go to
travel agent. They had to rate their speech during this
Client
Communication Effectiveness
Index pre score
Communication
Effectiveness Index
post score
AM
39
47
GC
50
61
Client
Modified Communication
Effectiveness Index pre
score
Modified
Communication
Effectiveness Index post
score
AM
43.5
45.5
GC
49.5
52.5
AH
43
62.5
Client
Communication Activity Log
pre score
Communication
Activity Log post
score
AM
37
45
GC
54
54
Client
Boston Naming Test pre
score (% Correct)
Boston Naming Test post
score (% correct)
AM
9 (15%)
13 (21.6%)
GC
31 (51.6%)
50 (83.3%)
AH
6 (10%)
9 (15%)

Barthel, G., Meinzer, M., Djundja, D., Rockstroh, B. (2007). Intensive language
therapy in chronic aphasia: Which aspects contribute the most? Aphasiology, 22 (4),
408-421.

Breier, J.I., Juranek, J., Maher, L.M., Schmadeke, S., Men, D., Papanicolaou, A.C.
(2009). Behavioural and Neurophysiologic Response to Therapy for Chronic Aphasia.
Arch Phys Med Rehabilitation. 90: 2026-33.

Cherney LR, Patterson JP, Raymer A, Frymark T, Schooling T. (2008)
Evidence-Based Systematic Review: Effects of Intensity of Treatment and ConstraintInduced Language Therapy for Individuals With Stroke-Induced Aphasia. Journal of
Speech, Language and Hearing Research 51 (5) :1282-1299.

Faroqi-Shah Y, Virion CR (2009) Constraint-induced language therapy for
aggrammaticality constraints. Aphasiology. 23 (7-8); 977-88.

Goral M, Kempler D (2009) Training verb production in communicative context:
evidence from a person with chronic non-fluent aphasia. Aphasiology. 23 (12) 138397.

Maher LM, Kendall D, Swearengin JA, Rodriguez A, Leon SA, Pingel K, Holland A,
Rothi LJ. (2006) A pilot study of use-dependent learning in the context of Constraint
Induced Language Therapy. Journal of the International Neuropsychological Society,
12 (6): 843-52.

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. Stroke, 36: 1462-1466.

Meinzer, M., Streiftau, S., Rockstroh, B. (2007). Intensive language training in the
rehabilitation of chronic aphasia: Efficient training by laypersons. Journal of the
International Neuropsychological Society, 13 (5), 1355-6177.

Pulvermuller R, Neininger B, Elbert T, Mohr B, Rockstroh B, Koebbel P, Taub E. (2001)
Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7): 1621-6.

Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM, Neils-Strunjas J,
NewmeyerA, Reichhardt R. (2008) Constraint-induced aphasia therapy stimulates
language recovery in patients with chronic aphasia after ischemic stroke. Medical
Science Monitor, 14 (5) 243 – 250.

Virion, C.R. (2008). “Go Aphasia”: Examining the efficacy of constraint induced
language therapy for individuals with agrammatic aphasia. –Thesis