Effect of Intensity and CILT in Aphasia: A systematic review

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Effect of Intensity and CILT in Aphasia A
systematic review

• Janet Patterson, California State University
  East Bay
• Anastasia Raymer, Old Dominion University,
  Norfolk, VA
• Leora Cherney, Rehabilitation Institute of
  Chicago
• Tobi Frymark, ASHA
• Tracy Schooling, ASHA
• Rob Mullen, ASHA

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Evidence-Based Practice at ASHA

• Focused Initiative since 2005
• Advisory Committee on Evidence-Based Practice
  established in 2005
• National Center for Evidence-Based Practice
  (N-CEP) established in 2005

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N-CEPs Mission

• Stimulate research
• high quality
• high relevance
• Educate membership
• what EBP is and is not
• development of needed skills
• Facilitate
• make EBP as painless as possible

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Principles of EBP
clinical expertise
clinical decision-making
scientific evidence
patient values
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EBSR Topic Selection

• ASHAs criteria for prioritizing topics
• Incidence/prevalence
• Risk/potential harm
• Public policy or reimbursement issues
• Importance to clients consumers
• Answerable question
• Representation of diverse areas of practice
• Existence of other systematic reviews/guidelines
• Level of interest among ASHA membership
• Existence of studies currently underway

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Why CILT?

• Public policy or reimbursement issues
• Of considerable importance to funding agencies,
  third party payors
• Several CILT clinics have been established across
  the country
• Private clinics charging out-of-pocket
• Importance to clients consumers
• CILT has been (incorrectly) described as the only
  aphasia treatment with evidence
• It has an internet presence

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Why CILT?

• Level of interest among ASHA membership
• Has received considerable interest in the field
  of aphasiology
• Based on Constraint Induced Movement Therapy
  (CIMT) research
• Evidence for CIMT in patients with restricted
  limb use due to neuronal injury (Stroke Cerebral
  palsy TBI Spinal cord injury)
• Existence of studies currently underway in
  aphasia literature
• Proposed by ASHA Division 2

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EBSR Process

• Identify evidence panel
• selected by N-CEP based on
• input from ASHA Special Interest Divisions
• input from ASHA National Office staff
• review of who has published on this topic
• Define clinical questions search parameters
• Conduct literature search
• NCEP Information manager
• Critically appraise the evidence
• Evaluate synthesize evidence
• Write EBSR summary

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EBSR Committee

• Evidence Panel
• Janet Patterson, Ph.D., CCC-SLP
• California State University East Bay
• Hayward CA
• Anastasia Raymer, Ph.D., CCC-SLP
• Old Dominion University
• Norfolk VA
• Leora Cherney, Ph.D., CCC-SLP,
• BCNCD-A
• Rehabilitation Institute of Chicago
• Chicago IL

• ASHAs National Center for Evidence-Based
  Practice in Communication Disorders
• Tobi Frymark, M.A. CCC-SLP
• Tracy Schooling, M.A., CCC-SLP
• Beverly Wang, B.S.

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Principles of CILT

• Forced verbal language use
• Verbalization required Compensatory strategies
  prohibited
• Intensive treatment schedule
• 3 hrs/day 5 days/week 2 weeks
• Massed practice
• Shaping verbal responses
• Begin with words or short phrases
• Move to longer and more complex utterances
• Barrier games
• Go Fishlike activity pictures selected for
  individual participants response components
  predetermined
• Initial publication Pulvermuller et al. (2001)
  Constraint-Induced Therapy
• of chronic aphasia after stroke. Stroke, 32,
  1621-1626.

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CIMT

• (Mark Taub, 2004)

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Framing the clinical question

• Two principles of CILT are intertwined
• Constraint
• Intensive/Massed practice
• PICO (Population-Intervention-Comparison-Outcome)
• P stroke-induced chronic aphasia,
• stroke-induced acute aphasia
• I CILT and intensive aphasia treatment
• C contrasting treatment or no treatment
• O measures of language impairment,
  communication activity/participation (WHO ICF)

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5 Intensity Questions

• For stroke-induced chronic aphasia, what is the
  influence of treatment intensity on measures of
  language impairment?
• For stroke-induced chronic aphasia, what is the
  influence of treatment intensity on measures of
  communication activity/participation?
• For stroke-induced acute aphasia, what is the
  influence of treatment intensity on measures of
  language impairment?
• For stroke-induced acute aphasia, what is the
  influence of treatment intensity on measures of
  communication activity/participation?
• For stroke-induced chronic aphasia, what
  treatment outcomes are maintained following
  intensive language treatment?

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5 CILT Questions

• For stroke-induced chronic aphasia, what is the
  influence of constraint-induced language therapy
  on measures of language impairment?
• For stroke-induced chronic aphasia, what is the
  influence of constraint-induced language therapy
  on measures of communication activity/participatio
  n?
• For stroke-induced acute aphasia, what is the
  influence of constraint-induced language therapy
  on measures of language impairment?
• For stroke-induced acute aphasia, what is the
  influence of constraint-induced language therapy
  on measures of communication activity/participatio
  n?
• For stroke-induced chronic aphasia, what
  treatment outcomes are maintained following
  constraint-induced language therapy?

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Search Parameters

• Inclusion
• Peer-reviewed literature from 1990 to 2006
• Written in English
• Adults ages 18 years or older
• Stroke-induced aphasia
• Direct comparison of CILT with other treatment
  approach or no treatment or direct comparison of
  two treatment intensities
• Exclusion
• Studies including individuals with underlying
  cognitive deficits
• Other primary medical diagnoses
• Pharmacological intervention as comparison
  treatment
• Mixed treatments

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Literature Search
441 potential citations for inclusion in
EBSR 36 studies initially included pertaining
to Intensity of language treatment CILT 10
studies included in final analysis 5 CILT 6
intensity
405 excluded Not a study Study included subjects
with non-stroke diagnoses or pharmacological
treatment Did not address intensity or amount
of treatment or CILT 26 studies excluded 3 did
not include original data 23 did not include
direct evidence
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Included Studies

• CILT Intensity
• Maher et al., 2006 Basso Caporali, 2001
• Meinzer et al., 2004 Denes et al., 1996
• Meinzer et al., 2005 Hinckley Craig, 1998
• Pulvermuller et al., 2001 Hinckley Carr, 2005
• Pulvermuller et al., 2005 Pulvermuller et al.,
  2001
• Raymer et al., 2006

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Rating the Evidence

• ASHAs Levels of Evidence Scheme
• Developed by ACEBP N-CEP
• Evaluates state of the evidence by methodological
  quality stage of research
• 2 reviewers clinically sifted studies for
  inclusion
• Blind reviewers
• 91 agreement
• 2 reviewers appraised studies for quality
• Blind reviewers
• One article authored by committee member (AMR)
  was reviewed by two other reviewers (JP, LC)
• All disagreements resolved by consensus
• 3 reviewers determined stage of research

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Evaluating the Evidence - Methodological Quality

• ASHA Levels of Evidence Scheme (Mullen, 2007)
• Similar to PEDRO scale (Maher et al., 2003)
• 9 dimensions Highest quality
• Study Design Controlled trial
• Blinding Assessors blinded
• Sampling Random sample adequately described
• Group Comparability/ Groups comparable at
  baseline or
• Participants described Participants well
  described
• Treatment Fidelity Evidence provided
• Outcomes Valid reliable outcome measure
• Significance p value reported/calculable
• Precision Effect size confidence interval
  reported/calculable
• Intention to Treat Analyzed by intention to
  treat
• (controlled trials only)

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Evaluating the Evidence - Stage of Research

• Is therapy delivered under optimal or real
  world conditions?
• Optimal Real World
• Is the study a controlled trial? Does the
  study address the public health or policy
  
  implications of the therapy
  
  protocol?
• NO YES NO YES
• Discovery Efficacy Effectiveness
  Cost-benefit/ public policy
  
  
  research

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Continuum of Research Stage

• Discovery - Treatment approaches are developed,
  assessed, and refined evaluated for potential
  promising outcomes.
• Efficacy - Promising interventions are tested in
  a rigorous way under ideal, highly controlled
  conditions to determine the outcome that result.
• Effectiveness - The intervention is tested in a
  real world clinical setting. This phase is
  often conducted if the intervention demonstrates
  positive outcomes in a highly controlled setting
  of a clinical trial.
• Cost-benefit/public policy research - A study is
  conducted of the political and economic
  environment in which the intervention is best
  delivered. This phase is often conducted once it
  has been shown than an intervention is both
  efficacious and effective.

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highest quality indicators across 10 studies of
the EBSR

• Design Controlled trial 5
• Assessor blinded 2
• Random sample well-described 1
• Comparable groups/
• Participants well-described 10
• Treatment fidelity 2
• Valid outcomes 9
• Significance calculable 10
• Precision calculable 7
• Intention to treat 3/5

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Stage of Research

• Discovery studies 4
• Efficacy studies 5
• Effectiveness studies 1
• Cost-benefit/public policy research 0

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Quality Scores Effect Sizes (d) CILT
StudiesImpairment Outcomes

• Score Outcome measure d
• Maher et al., 2006 6/9 WAB AQ 1.2
• BNT -.19
• ANT .35
• Meinzer et al., 2004 4/8 AAT TT .76
• AAT Profile .88
• Pulvermuller et al., 2005 3/8 AAT TT .27
• Repetition .11
• Naming .26
• Comprehension .48
• Meinzer et al., 2005 5/9 AAT, TT Not calculable
• Pulvermuller et al., 2001 6/9 AAT TT Not
  calculable

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Quality Scores Effect Sizes (d) CILT
StudiesActivity/Participation Outcomes

• Score Outcome measure d
• Maher et al., 2006 6/9 story
  retelling not calculable
• Meinzer et al., 2004 4/8 none
• Pulvermuller et al., 2005 3/8 none
• Meinzer et al., 2005 5/9 CAL, CETI not
  calculable
• Pulvermuller et al., 2001 6/9 CAL not
  calculable

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Quality Scores Effect Sizes (d) Intensity
studiesImpairment Outcomes

• Score Outcome measure d
• Denes et al., 1996 7/9 AAT TT .63
• Repetition .40
• Written Lang 1.22
• Naming .75
• Comprehension .93
• Profile .86
• Hinckley Craig, 1998 4/8 BNT .84
• Hinckley Carr, 2005 7/9 none
• Raymer et al., 2006 5/8 Picture Naming Low
  4.35 High 11.37
• (SSD) Pic Name Maint Low 4.85 High 7.45
• Comprehension Low 2.72 High 2.14
• Comp Maint Low 2.14 High 1.75
• Basso Caporali, 2001 4/8 TT, Ravens
  not calculable

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Quality Scores Effect Sizes (d) Intensity
studiesActivity/Participation Outcomes

• Score Outcome measure d
• Denes et al., 1996 7/9 none
• Hinckley Craig, 1998 4/8 Content Units .71
• Hinckley Carr, 2005 7/9 Catalogue order
• Oral (Quiet) -.83
• Oral (Concurrent) -.04
• Written (Quiet) -.56
• Written (Concurrent) -1.36
• Raymer et al., 2006 5/8 none
• Basso Caporali, 2001 4/8 Picture
  description not calculable
• Pulvermuller et al., 2001 6/9 CAL not
  calculable

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Findings - Treatment Intensity

• 6 studies with 68 participants
• Language impairment measures Increased treatment
  intensity was associated with positive changes in
  both chronic and acute aphasia.
• Activity/Participation measures Equivocal
  results, favoring neither more intensive nor
  less intensive treatment for persons with chronic
  aphasia.
• Maintenance of treatment little data also
  equivocal, favoring more intense treatment for
  one outcome measure and less intense for the
  other.
• Observations suggest that there can be complex
  interactions among intensity of treatment
  schedule, type of treatment, and type of outcome
  measure.

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Findings - CILT

• 5 studies with 90 participants
• Language impairment measures CILT resulted in
  positive changes
• Communication activity/participation measures
  CILT reported to lead to positive changes, though
  no effect sizes calculable
• Data available only for chronic aphasia. No data
  speak to the effects of CILT in acute aphasia.
• Maintenance of CILT effects reported to lead to
  positive changes again no effect sizes
  calculable.

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Future Research

• Across studies, majority of participants were
  nonfluent and moderately impaired therefore
  generalizability of results is limited for
  individuals with fluent aphasia and individuals
  with mild and severe aphasia.
• Future studies need to tease out more carefully
  the impact of constraint and intensity on
  outcome.
• Future research must be designed according to the
  criteria included in the ASHA levels of evidence
  scheme to ensure that they are of highest
  quality.
• Future studies should address issues of
  effectiveness and cost effectiveness.

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Summary

• Early data on CILT show promise
• However, not yet possible to tease apart effects
  of constraint and intensity
• Regardless of treatment type, more treatment over
  a restricted time appears better
• The interaction between treatment type,
  intensity, and outcome (impairment,
  activity/participation) is complex and yet to be
  determined

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• Questions?