Aphasia Treatment: Evidence-based Practice and The State of the Evidence

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Aphasia TreatmentEvidence-based Practice and
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

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• Objectives
• Define Evidence-based Practice and identify a
  system for evaluating the strength of the
  evidence
• Identify evidence for impairment-based treatment
  techniques
• Identify evidence for activity/participation-based
  treatment techniques
• Identify evidence for emerging treatment
  techniques

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Evidence-based Practice

• Evidence-based medicine is the integration of
  best research evidence with clinical expertise
  and patient values.
• (Sackett et al. Evidence-Based Medicine How to
  Practice and Teach EBM, 2nd edition.
• Churchill Livingstone, Edinburgh, 2000, p.1)

http//www.asha.org/members/ebp/intro.htm
A fourth component is the environment or facility
in which treatment takes place.
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Finding the evidence

• ASHA National Center for Evidence-Based Practice
  (N-CEP)
• http//www.asha.org/Members/ebp/default/
• ASHA Division 2
• http//www.asha.org/members/divs/div_2.htm
• ANCDS
• www.ancds.org

• PsycBITE Psychological Database for Brain
  Impairment Treatment Efficacy
• http//www.psycbite.com
• Agency for Healthcare Research and Quality
• http//www.guideline.gov/
• The Cochrane Collaboration
• http//www.cochrane.org/
• Centre for Evidence-Based Medicine
• http//www.cebm.net/

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SORTing the EvidenceBy Outcome Measures

• Patient-oriented evidence measures outcomes that
  matter to patients
• Disease-oriented evidence measures intermediate,
  physiologic, or surrogate end points that may or
  may not reflect improvements in patient outcomes

Ebell, Siwek, Weiss, Woolf, Susman, Ewigman
Bowman, 2004
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Grading the Evidence

• The grade of a recommendation for clinical
  practice is based on a body of evidence
  (typically more than one study). This approach
  takes into account
• 1) the level of evidence of individual
  studies
• 2) the type of outcomes measured by these
  studies
• (patient-oriented or disease-oriented)
• 3) the number, consistency, and coherence of
  the
• evidence as a whole and
• 4) the relationship between benefits, harms,
  and
• costs.

Ebell, et al., 2003
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• Strength of recommendation
• A Consistent, good-quality patient-oriented
  evidence
• B Inconsistent or limited-quality
  patient-oriented evidence
• C Consensus, disease-oriented evidence, usual
  practice, expert opinion, or case series for
  studies of diagnosis, treatment, prevention, or
  screening

Ebell, et al., 2003
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ASHA Evidence

• National Center for Evidence-based Practice
• Compendium of evidence
• Systematic Reviews
• Evidence Maps
• Advisory Committee on Evidence-based Practice
• Guides the work of N-CEP
• Identify clinical questions

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ASHA Homepage gt Research Tab gt Evidence-based
Practice
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ANCDS Evidence

• Writing Groups
• Practice Guidelines

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Cautions

• Study quality Strength of evidence
• Practice
  Guidelines
• Methodology is often inconsistent
• The lack of evidence poor evidence
• Consider all EBP components in treatment decisions

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A Word about Effect size

• Many methods of calculation
• Most common method references means and
  variability of two groups
• d (M post-treatment M pre-treatment)
• SD Pre-treatment
• Between or within subjects
• .2 small .5 medium .8 large (Cohen,
  1962)
• Single subject designs (Beeson Robey, 2008)

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Aphasia Treatment
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Aphasia language treatment

• Treatment is beneficial
• Kelly, Brady Enderby (2010)
• http//onlinelibrary.wiley.com/o/cochrane/clsysrev
  /articles/CD000425/frame.html
• Robey (1998, 1994)
• Salter, Teasell, Bhogal, Zettler, Foley (2010)
• http//www.ebrsr.com/reviews_list.php
• Insufficient evidence to state which treatment
  for which patient in which dosage

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Impairment-based treatment techniques

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Impairment-based treatment techniques

• Lexical retrieval
• Constraint-Induced Language Treatment
• Cueing Hierarchy
• Semantic Feature Therapy
• Reading
• Writing
• Complexity Account of Treatment Effectiveness

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Lexical Retrieval
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Theoretical Foundation

• Semantic network or feature network
• A way of thinking about knowledge in which there
  are concepts and relationships among them.
• A diagrammatic representation comprising some
  combination of boxes, arrows and labels.
• Storage, central processing or retrieval deficit

Collins Loftus, 1975
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Example of a semantic network
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• A concept (bird) defined as set of features
• defining features - necessary to the meaning of
  the item (robin has a red breast)
• characteristic features - descriptive but not
  essential
• How close is target to exemplar
• Target chicken, sparrow, robin, penguin
• Exemplar robin

Smith, Shoben Rips, 1974
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Example of semantic feature set
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Cognitive neuropsychological processing model of
word retrieval
Kay, Lesser Coltheart, 1992
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Treatment examples

• Stimulation-facilitation (Schuell, 1964)
• Cues
• Cueing hierarchy (Linebaugh Lehner, 1977
  Patterson, 2001)
• Semantic or Phonologic (Raymer et al., 1993
  Wambaugh et al., 2002)
• Personal cues (Marshall, Karow, Freed Babcock,
  2002)
• Semantic Features (Boyle Coelho, 1995)
• Gesture (Raymer, Singletary, Rodriguez ,
  Ciampitti, Heilman Rothi , 2006 Rose, Douglas
  Matyas, 2002)

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Evidence, ES Conclusions

• Evidence
• Some RCTs but not large scale clinical trials
• No Systematic Reviews
• One meta analyses (Wisenburn Mahoney, 2009)
• Many single subject designs or case studies
• Effect Sizes
• Robey Beeson (2005) reported tentative ES of
  4.0, 7.0 and 10.1 calculated from 12 studies
• Point is that Cohens d is meant for group
  studies and much of our work is single subject
  studies, requiring a different comparison
• Compare an individual study to these benchmarks

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Task Specific v General
Individual v Group
SLP v Volunteer
Conventional v Functional
Treatment v Social Support
Treatment v No Treatment
Kelly, Brady Enderby, 2010
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• Consistent results across sources of evidence
• RCT, EBSR, individual review
• Moderate to strong evidence in favor of treatment
• Task specific and item specific effects
• Phonological v semantic cueing
• Noun v verb training
• Weak evidence in favor of generalization to
  untreated items and maintenance
• Insufficient evidence to state which treatment
  for which patient in which dosage

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Constraint Induced Language Therapy
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Theoretical Foundation

• Pulvermller et al. (2001) reasoned that
  principles of CIMT could be applied to aphasia
  treatment
• Learned non use observed in persons with aphasia
• Failed communicative attempts punished (i.e.
  frustration or embarrassment) leading to even
  fewer attempts
• Compensatory communication attempts rewarded and
  thus prevail
• Fewer and more difficult communicative attempts
  occurred
• Does use it to improve it apply to language
  change in persons with aphasia?

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Principles of CILT

• Forced verbal language use and application of
  constraint
• Verbalization required
• Compensatory strategies prohibited (constrained)
• Intensive treatment schedule
• Massed practice
• 3 hrs/day 5 days/week 2 weeks
• Shaping verbal responses
• Begin with words or short phrases
• Move to longer and more complex utterances

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Model
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Use dependent Cortical Reorganization

• Neuronal plasticity
• Events that regulate the capacity of the CNS to
  change in response to injury or physiological
  demands
• Potential for change
• Several mechanisms of change
• (i.e. synaptogenesis, dendritic arborization)

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CIMT example (Mark Taub, 2004)
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CILT Intensity Questions

• 10 questions (PICO format)
• Influence of CILT (5)
• Influence of Treatment Intensity (5)
• Two factors
• Aphasia Acute vs. chronic
• Outcome measure Impairment vs.
  Activity/Participation
• Maintenance Question (Intensity CILT)

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Studies included in two reviews Cherney,
Patterson, Raymer, Frymark, Schooling (2008,
2010)CILT

• Berthier et al., 2009
• Breier et al., 2006, 2007, 2009
• Faroqi-Shah et al., 2009
• Goral Kempler, 2009
• Kirness Maher, 2010
• Maher et al., 2006

• Meinzer et al., 2004, 2005, 2006, 2007a, 2007b,
  2008, 2009
• Pulvermuller et al., 2001, 2005
• Richter et al., 2008
• Szaflarski et al., 2008

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Intensity

• Bakheit, et al., 2007
• Basso Caporali, 2001
• Denes et al., 1996
• Harnish et al., 2008
• Hinckley Carr, 2005

• Hinckley Craig, 1993
• Puvermuller et al., 2001
• Ramsberger Marie, 2007
• Raymer et al., 2006

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CILT

• 19 studies with 202 participants
• Language impairment measures CILT resulted in
  positive changes
• Communication activity/participation measures
  CILT resulted in positive language outcome
  measure changes one large effect size
• Data available mostly for people with chronic
  aphasia. One study showed positive effect for 3
  individuals with acute aphasia.
• Maintenance of CILT effects reported to lead to
  positive changes again no effect sizes
  calculable
• Evolution of studies Relatives Reduce time
  pharmacotherapy RH activation syntax module
  multiple activities

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Treatment Intensity

• 9 studies with 170 participants
• Language impairment measures Increased treatment
  intensity was associated with positive changes in
  both chronic and acute aphasia.
• BUT-Bakheit et al., with 97 participants (more
  than ½) showed no effect of intensity
• Activity/Participation measures Bakheit et al.,
  results notwithstanding, equivocal results,
  favoring neither more intensive nor less
  intensive treatment for persons with chronic
  aphasia.
• Observations suggest that there can be complex
  interactions among intensity of treatment
  schedule, type of treatment, and type of outcome
  measure.
• Maintenance of treatment little data also
  equivocal, favoring more intense treatment for
  one outcome measure and less intense for the
  other.

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Effect Sizes favoring Constraint Induced
Language Treatment for Impairment and
Activity/Participation outcome measures
Activity Participation
Impairment
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Activity/participation Based treatment techniques
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Blackstone Hunt Berg, 2006
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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)
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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)

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Activity/Participation-based treatment techniques

• Group treatment
• Conversation participation
• Treatment for caregivers or conversation partners
• Personal narratives scripts
• AAC

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Group treatment
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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)

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Evidence, ES and Conclusions
Effect Sizes for Group vs. Individual Treatment
--- RCTs ---
Kelly, Brady, Enderby, 2010
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Change Scores and Total Number of Participants
for Studies of Group Treatment
Change Score
Salter, Teasell, Bhogal, Zettler Foley (2010)
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• 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

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• 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
  communicating
• 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

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Conversation participation
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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, Munoz Bourgeois, 2005)
• Insertion into connected speech situation

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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
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More Conversation 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

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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

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• Partner training
• Facilitate desirable behavior or inhibit
  undesirable behavior by partner
• Evidence
• Effective for improving communication of partner
• Probably effective for persons with chronic
  aphasia
• Insufficient evidence for persons with acute
  aphasia or changing language impairment,
  psychosocial adjustment or quality of life

Simmons-Mackie et al., 2010 Turner Whitworth,
2006 http//www.asha.org/members/reviews.aspx?id
7499
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• Anecdotal outcome reports
• 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
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More Conversation 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

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• 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

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Treatment Influences
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Intensity and Dosage

• Theories supporting treatment intensity
• Hebbian cell assemblies (Hebb, 1949)
• Education learning theory http//www.emtech.net/le
  arning_theories.htm
• Neuronal plasticity (Kleim Jones, 2008)
• Dosage (frequency, intensity, duration)
• Early aphasia treatment research (Darley, 1972)

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Activity/Participation
ES for Outcome Measures for studies investigating
intensity of treatment
Impairment
Cherney, Patterson, Raymer, Frymark Schooling,
2008 Frymark, Cherney, Patterson Raymer, 2010
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Errorless (Reduced Error) Learning

• Theoretical foundation
• Initially demonstrated in animal learning
• Memory rehabilitation
• Error behavior can be self-reinforcing gt
  eliminate
• Contrast
• Errorless learning
• Error elimination
• Error reduction
• Errorful learning (cueing hierarchy)
• Errors not controlled

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• 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)
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Neuronal Plasticity

• Principles of experience-dependent neural
  plasticity

• Use it or lose it
• Use it and improve it
• Specificity
• Repetition matters
• Intensity matters

• Time matters
• Salience matters
• Age matters
• Transference
• Interference

Kleim Jones, 2008 Raymer et al., 2008
Raymer, Maher, Patterson Cherney, 2007
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• 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

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Emerging Treatments
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Emerging treatment techniques

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

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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
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• Additional studies of drug therapy in aphasia
• Piracetam strong, positive evidence in favor
  (n5)
• Bromocriptine strong evidence against (n4)
• Levodopa moderate evidence in favor (n1)
• Amphetamines moderate evidence in favor (n2)
• Bifemelane insufficient evidence (n1)
• Dextran moderate evidence against (n1)
• Moclobemide insufficient evidence (n1)
• Donepizil moderate evidence in favor during
  active treatment (n2)
• Memantine moderate evidence in favor with CILT
  (n1)

Salter, Teasell, Bhogal, Zettler Foley, 2010
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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, Holland
  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
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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
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• 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
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• 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
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Summary

• Evidence-based medicine is the integration of
  best research evidence with clinical expertise
  and patient values
• N-CEP, PsychBITE, ANCDS, Division 2 are sources
  of evidence
• Aphasia therapy is effective dosage is unclear.
• Moderate evidence for effectiveness of lexical
  retrieval treatment weak evidence for
  generalization of treatment gains.
• Moderate evidence for effectiveness of CILT in
  chronic nonfluent aphasia.
• Moderate (small studies) or inconsistent (RCTs)
  support for group treatment.
• Modest support for script training (multiple
  forms).

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• Modest support for communication partner
  training.
• Modest support for PACE and RET
• Greater intensity may be more effective than
  lesser intensity
• Errorless, reduced error and errorful treatment
  techniques are effective
• Principles of neuronal plasticity positively
  influence treatment effectiveness
• Inconsistent evidence supporting pharmacological
  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.