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Aphasia

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Title: Aphasia


1
Aphasia Treatment effectiveness and evidence
based practice
2
Treatment Efficacy
  • Efficacy improvements in an individuals
    communication as a result of clinical
    interventions provided by an SLT
  • Difficult to combine results of studies due to
    differing
  • Aetiologies
  • Methodologies
  • Types and severity of aphasia
  • Nature of treatment
  • Enderby and Emerson 1995

3
Systematic Reviews
  • A scientific tool that can be used to appraise,
    summarise, and communicate the results and
    implications of otherwise unmanageable quantities
    of research
  • Brings together separately conducted studies and
    synthesise their results
  • E.g. Cochrane Database

4
Meta-analysis
  • A specific statistical strategy for assembling
    the results of several studies into a single
    estimate
  • Systematic reviews may or may not include
    meta-analysis, depending on whether the studies
    are similar enough so that combining their
    results is meaningful
  • Strictly speaking a meta-analysis is an optional
    component of a systematic review. Not
    inter-changable words!

5
Cochrane Systematic Reviews
  • Kelly, Brady and Enderby (2010)
  • 30 RCTs (involving 1840 participants) comparing
  • SLT vs no SLT
  • SLT versus social support or stimulation
  • One SLT intervention vs another intervention
  • In general, trials randomised small numbers
    across a range of characteristics (age, time
    since stroke, and severity), interventions and
    outcomes

6
Kelly, Brady and Enderby (2010)
  • Concluded some indication for the effectiveness
    of SLT for those with aphasia following stroke
    (as compared with Enderby 2006b).
  • Intense SLT was favoured over conventional SLT
  • Therapist-trained and supervised volunteers as
    effective as provision by a professional
  • Insufficient evidence for effectiveness of
    specific treatment approaches

7
Systematic Reviews
  • Greener, Enderby and Whurr (2006b)
  • RCTs for behavioural treatments for Aphasia by
    SLTs
  • 12 studies met criteria
  • All had limitations in methodology, and
    incompleteness in which operational definitions
    and outcomes were communicated.
  • Concluded RCTs had neither demonstrated efficacy
    nor lack of efficacy

8
Cochrane Review
  • Greener, Enderby and Whurr (2010)
  • Assessed the effects of drugs on language
    abilities for people with aphasia
  • Particularly examined Piracetam drug which
    improves memory, cognition, attention,
    concentration, motivation
  • Has reportedly shown improvements in post stroke
    aphasia in some studies
  • 10 trials included
  • Weak evidence that patients were more likely to
    have improved on language measures at the end of
    the trial with piracetam

9
Meta-analysis
  • Greenhouse et al (1990)
  • Analysed 13 pre-post tests of aphasia treatment
  • Average weighted effect size of 0.8 (medium to
    large effect of change) from pre-treatment to
    post treatment
  • Whurr Lorch and Nye (1992)
  • 45 aphasia treatment studies
  • Average effect size 0.59 between treated and
    untreated populations.
  • Concluded treatments were generally effective

10
Meta-Analysis
  • Robey (1998)
  • Analysis of 55 articles aphasia therapy brought
    about positive clinical outcomes
  • Positive outcomes were 1.83 times more likely for
    those treated in acute period than for untreated
    individuals. Advocating early intervention
  • Treatment length in excess of 2 hours per week
    brought about gains exceeding those of shorter
    treatment duration
  • Those with severe aphasia also made large gains
  • These findings confirmed findings from earlier
    study Robey (1994)

11
Meta-Analysis
  • Holland et al (1996)
  • Examined improvements in individuals
    communication behaviour resulting from clinical
    interventions from SLT and exceeding what could
    be expected from spontaneous recovery alone.
  • 9 group studies, all enrolling gt60 patients
  • Single, left hemi stroke, receiving gt3hrs/week
    therapy for gt5m regardless of time post onset,
    made significantly more improvement than people
    with aphasia who were not treated
  • 13 small group/single subject studies past period
    of spontaneous recovery. Gains made in most
    studies contributing to efficacy of chronic
    aphasia

12
Treatment of Word Retrieval Deficits in Aphasia
  • Summary
  • Task specific semantic therapy improves semantic
    activities
  • Task specific phonological therapy improves
    phonological activities
  • Limited evidence that semantic and phonological
    cueing improve naming accuracy and word retrieval
    abilities
  • Salter,Teasell, Bhogal, Zettler, Foley (2009)
  • Evidenced Based Review of Stroke Rehabilitation

13
Doesborg et al 2004
  • RCT of 55 stroke patients 3-5m post onset
  • Combined semantic and phonological deficits
  • Randomly assigned to
  • Semantic treatment focused on interpretation of
    written words, sentences and text (e.g. semantic
    categories, anomalous sentences, semantic
    definitions)
  • Control group focused on word sound structure
    (e.g. rhyming, word length, stress patterns,
    syllabification)

14
Doesborg et al 2004
  • Treatment lasted until 10-12m post onset,
    receiving 40-60 hours individual treatment
  • After semantic treatment patients significantly
    improved on Semantic Association Test.
  • After sound structure treatment patients
    significantly improved on phonological measures
  • All patients improved on Everyday Language Test
  • Improved verbal communication was achieved for
    both groups

15
Treatment for Word Finding in Aphasia Nickels
(2010)
  • Therapy has item specific effects only
  • Semantic and phonologically focused treatments
    are mostly successful in improving word
    retrieval.
  • Semantic tasks dont have to be hard to be
    effective
  • Semantic tasks are more effective with those with
    less semantic impairment
  • Semantic tasks usually require the word form to
    be effective

16
Treatment of Global Aphasia
  • Summary
  • Patients with global aphasia experience less
    complete or slower rates of recovery
  • Can still benefit from an SLT rehab programme
  • Moderate evidence based on small RCT that
    intensive ecological language therapy is
    associated with improvement across modalities
  • Salter,Teasell, Bhogal, Zettler, Foley (2009)
  • Evidence Based Review of Stroke Rehab

17
Denes et al 1996
  • RCT of 17 patients with global aphasia
  • Random allocation to standard (60 sessions over
    6m) or intensive therapy (130 over 6m)
  • Approach in both groups ecological
    restoration of language in conversation
  • Comprehension targeted gt production
  • Sessions 45-60min
  • Assessed at baseline and 6m Aachen Aphasia Test

18
Denes et al 1996
  • Results
  • Both groups demonstrated improvement across all
    subtests.
  • Between group differences significant for written
    language subtest only

19
Aphasia Treatment in Polyglots
  • Miertsch, Meisel and Isel (2009)
  • Does treatment of 1 language lead to improvement
    in all languages?
  • 56yr old male, speaking German (L1), English (L2)
    and French (L3)
  • Left CVA with a medium Wernickes aphasia severe
    WFD, semantic paraphasias, paragrammatism.
    Auditory language processing and phonological
    working memory worse than visual language
    processing
  • Therapy for the study 8yrs post onset. 2x
    45min/day for 3.5weeks in French.

20
Therapy
  • Bilingual Aphasia Test administered
  • 5 exercise types in same order every day.
  • Therapy focussed on
  • Oral and auditory word finding of verbs and nouns
  • Exercises with prepositions
  • Semantic-conceptual relationships between words
  • Word finding in discourse

21
Results
  • Before training best performance German.
  • Post treatment, performance improved
    significantly in French as well as English.
    German did not improve.
  • Further evidence that chronic aphasia can improve
  • 2 Languages share a common semantic-conceptual
    memory system, though would expect improvement in
    German too. ?Length of training too short ?due to
    capabilities in that language prior to training.

22
Conclusions
  • Generally accepted that SLT works!
  • Basso (2005), Albert (2003), Bhogal, Teasell and
    Speechley (2003)
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