Title: Aphasia Treatment: Evidence-based Practice and The State of the Evidence
1Aphasia 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
2- 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
3Evidence-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.
4Finding 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/
5SORTing 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
6Grading 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
7- 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
8ASHA 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
9ASHA Homepage gt Research Tab gt Evidence-based
Practice
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16ANCDS Evidence
- Writing Groups
- Practice Guidelines
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19Cautions
- Study quality Strength of evidence
- Practice
Guidelines - Methodology is often inconsistent
- The lack of evidence poor evidence
- Consider all EBP components in treatment decisions
20A 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)
21Aphasia Treatment
22Aphasia 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
23Impairment-based treatment techniques
24Impairment-based treatment techniques
- Lexical retrieval
- Constraint-Induced Language Treatment
- Cueing Hierarchy
- Semantic Feature Therapy
- Reading
- Writing
- Complexity Account of Treatment Effectiveness
25Lexical Retrieval
26Theoretical 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
27Example of a semantic network
28- 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
29Example of semantic feature set
30Cognitive neuropsychological processing model of
word retrieval
Kay, Lesser Coltheart, 1992
31Treatment 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)
32Evidence, 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
33Task Specific v General
Individual v Group
SLP v Volunteer
Conventional v Functional
Treatment v Social Support
Treatment v No Treatment
Kelly, Brady Enderby, 2010
34- 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
35Constraint Induced Language Therapy
36Theoretical 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?
37Principles 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
38Model
39Use 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)
40CIMT example (Mark Taub, 2004)
41CILT 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)
42Studies 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
43Intensity
- 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
44CILT
- 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
45Treatment 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.
46 Effect Sizes favoring Constraint Induced
Language Treatment for Impairment and
Activity/Participation outcome measures
Activity Participation
Impairment
47Activity/participation Based treatment techniques
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49Blackstone Hunt Berg, 2006
50Life 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)
51Outcome 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)
52Activity/Participation-based treatment techniques
- Group treatment
- Conversation participation
- Treatment for caregivers or conversation partners
- Personal narratives scripts
- AAC
53Group treatment
54Types 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)
55Evidence, ES and Conclusions
Effect Sizes for Group vs. Individual Treatment
--- RCTs ---
Kelly, Brady, Enderby, 2010
56Change Scores and Total Number of Participants
for Studies of Group Treatment
Change Score
Salter, Teasell, Bhogal, Zettler Foley (2010)
57- 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
58- 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
59Conversation participation
60Script 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
61Supported 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
62More 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
63Evidence, 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
64- 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
65- 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
66More 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
67- 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
68Treatment Influences
69Intensity 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)
70Activity/Participation
ES for Outcome Measures for studies investigating
intensity of treatment
Impairment
Cherney, Patterson, Raymer, Frymark Schooling,
2008 Frymark, Cherney, Patterson Raymer, 2010
71Errorless (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
72- 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)
73Neuronal 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
74- 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
75Emerging Treatments
76Emerging treatment techniques
- Pharmacotherapy
- Computer-aided treatment
- Repetitive Transcranial Magnetic Stimulation
(rTMS) - Transcranial Direct Current Stimulation (tDCS)
- Epidural cortical stimulation
77Pharmacotherapy
- 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
78- 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
79Computer-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
80Cortical 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
81- 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
82- 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
83Summary
- 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).
84- 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.