Aphasia Treatment:Evidence-based Practice and The State

of the Evidence

Janet Patterson, Ph.D., CCC-SLPVA Northern California Healthcare System

Martinez CAand

California State University East Bay Hayward CA

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

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.

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/

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

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

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

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

ASHA Homepage > Research Tab > Evidence-based Practice

ANCDS & Evidence

• Writing Groups

• Practice Guidelines

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

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)

APHASIA TREATMENT

Aphasia language treatment

• Treatment is beneficial– Kelly, Brady & Enderby (2010) • http://onlinelibrary.wiley.com/o/cochrane/clsysrev/arti

cles/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

IMPAIRMENT-BASED TREATMENT TECHNIQUES

Impairment-based treatment techniques

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

Effectiveness

LEXICAL RETRIEVAL

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

Example of a semantic network

• 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

Example of semantic feature set

Cognitive neuropsychological processing model of word retrieval

Kay, Lesser & Coltheart, 1992

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)

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 Cohen’s 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

BNTWAB Naming

Object Naming TestWord Fluency

PALPAAAT

AATPICA

AATPICA

NamingNaming

Treated items

0 2 4 6 8 10 12 14

RCT Effect Size favoring treatment for naming outcome measure

Effect Size

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

• 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

CONSTRAINT INDUCED LANGUAGE THERAPY

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?

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

Model

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)

CIMT example (Mark & Taub, 2004)

CILT & Intensity Questions10 questions (PICO format)

Influence of CILT (5)Influence of Treatment Intensity (5)

Two factorsAphasia: Acute vs. chronic

Outcome measure: Impairment vs. Activity/Participation

Maintenance Question (Intensity & CILT)

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

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

CILT19 studies with 202 participantsLanguage 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

Treatment Intensity 9 studies with 170 participantsLanguage 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.

Effect Sizes favoring Constraint Induced Language Treatment for Impairment and Activity/Participation outcome measures

Activ

ity P

artic

ipati

onIm

pairm

ent

WAB AQAAT ProfileAAT Profile

AAT Profile Relative trainedAAT Profile Therapist trained

AAT TTAAT TTAAT TT

ANELT ACANELT SC

ANTBDAE-3 ACBDAE-3 VE

BNTComprehension

LCIMemantine+CIAT prepost (Naming)

Memantine+CIAT v Placebo+CIATNaming

RepetitionSeverity

AATSpontaneous Speech# Utterances

Different root wordsMemantine+CIAT prepost (CAL)

Proportion of sentencesProportion of well-formed sentences

Tense accuracyTense diversity

Total # words

-0.2 0.8 1.8 2.8 3.8 4.8 5.8 6.8

ACTIVITY/PARTICIPATION BASED TREATMENT TECHNIQUES

Blackstone & Hunt Berg, 2006

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)

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)

Activity/Participation-based treatment techniques

• Group treatment• Conversation participation• Treatment for caregivers or conversation

partners• Personal narratives; scripts• AAC

GROUP TREATMENT

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)

Effect Sizes for Group vs. Individual Treatment --- RCTs ---

AAT Comprehension Subtest

AAT Naming Subtest

AAT Overall

AAT Repetition Subtest

PICA Gestural Subtest

PICA Graphic

PICA Overall

PICA Verbal Subtest

Token Test

Token Test

WAB AQ

WAB AQ

-5.1 14.9 34.9 54.9

Kelly, Brady, Enderby, 2010

Evidence, ES and Conclusions

AttitudeCADL

CADLCADL

Communicative

compete

ncePICA

PICAPICA

PICA

WAB AQ

0

10

20

30

40

50

60

70

80

Participants showing positive change

Number of participants

Chan

ge S

core

Salter, Teasell, Bhogal, Zettler & Foley (2010)

Change Scores and Total Number of Participants for Studies of Group Treatment

• 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

• 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

CONVERSATION PARTICIPATION

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, Muňoz &Bourgeois, 2005)

• Insertion into connected speech situation

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

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

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

• 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

– Anecdotal outcome reports• Improved interaction

– More successful conversation turns– Fewer interruptions– Fewer turns devoted to repair

• Successful social validation• More accurate sense of partner’s aphasia• Maintenance and generalization of behavior

Turner & Whitworth, 2006

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

• 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

TREATMENT INFLUENCES

Intensity and Dosage

• Theories supporting treatment intensity– Hebbian cell assemblies (Hebb, 1949)

– Education learning theory http://www.emtech.net/learning_theories.htm

– Neuronal plasticity (Kleim & Jones, 2008)

– Dosage (frequency, intensity, duration)

• Early aphasia treatment research (Darley, 1972)

AAT Langugae ComprehensionAAT Naming

Fable retell-MLUFable retell-TTR

Fable retell-utterancesFable retell-words

NamingNamingNamingNamingNamingNamingNaming

Picture Naming-Acquisition-hiPicture Naming-Acquisition-lo

Picture Naming-Maintenance-hiPicture Naming-Maintenance-lo

WAB AQWAB AQWAB AQWAB AQ

Word/Picture Verification-Acquisition-hiWord/Picture Verification-Acquisition-lo

Word/Picture Verification-Maintenance-hiWord/Picture Verification-Maintenance-lo

CADL-2Catalogue order-oral-dual task

Catalogue order-oral-quietCatalogue order-written-dual task

Catalogue order-written-quietCommunication Activity Log-Patients

Communication Activity Log-SLPs2.64Content Analysis

Content Units

-1.2 0.8 2.8 4.8 6.8 8.8 10.8 12.8

Impa

irmen

tAc

tivity

/Par

ticip

ation

ES for Outcome Measures for studies investigating intensity of treatment

Cherney, Patterson, Raymer, Frymark & Schooling, 2008; Frymark, Cherney, Patterson & Raymer, 2010

Errorless (Reduced Error) Learning• Theoretical foundation– Initially demonstrated in animal learning– Memory rehabilitation – Error behavior can be self-reinforcing > eliminate

• Contrast– Errorless learning• Error elimination• Error reduction

– Errorful learning (cueing hierarchy)• Errors not controlled

• 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)

Neuronal PlasticityPrinciples 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

• 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

EMERGING TREATMENTS

Emerging treatment techniques

• Pharmacotherapy• Computer-aided treatment• Repetitive Transcranial Magnetic Stimulation

(rTMS)• Transcranial Direct Current Stimulation (tDCS)• Epidural cortical stimulation

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

• Additional studies of drug therapy in aphasia– Piracetam – strong, positive evidence in favor (n=5)

– Bromocriptine – strong evidence against (n=4)

– Levodopa – moderate evidence in favor (n=1)

– Amphetamines – moderate evidence in favor (n=2)

– Bifemelane – insufficient evidence (n=1)

– Dextran – moderate evidence against (n=1)

– Moclobemide – insufficient evidence (n=1)

– Donepizil – moderate evidence in favor during active treatment (n=2)

– Memantine – moderate evidence in favor with CILT (n=1)

Salter, Teasell, Bhogal, Zettler & Foley, 2010

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

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 Broca’s 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

• 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

• 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

SummaryEvidence-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).

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.