Using Neuroscience to understand aphasia recovery

1. UCL INSTITUTE OF NEUROLOGY Using Neuroscience to understand aphasia recovery Shedding some light into the darkness!

2. Who are we? Louise Lim Research Associate and Speech & Language Therapist Johanna Rae Research Assistant (Bilingual) and Speech & Language Therapist From: University College London, Institute of Neurology, Wellcome Trust Centre for Neuroimaging

3. Prof Cathy Price Dr Alex Leff PLORAS The patient-facing team Louise Lim ZulaHaigh Rachel Browne Johanna Rae

4. Aphasia • An acquired language disorder following brain injury. • Affects a third of stroke survivors • Can involve understanding language, speaking, reading and writing • One of the most feared outcomes after stroke (Soloman, Glick, Russo, Lee and Schulman, 1994)

5. Impact of Aphasia on Carers Communication difficulties due to aphasia following stroke are particularly difficult for caregivers… isolation identity role-change depression stress helplessness

6. From the literature • Most studies conclude that: • Caregivers of aphasic stroke patients are more stressed, • with symptoms of depression, loneliness and other • emotional problems than caregivers of non-aphasic stroke • patients. • Their (carers of people with aphasia’s) overall adjustment • to the stroke is poorer and they experience greater role • changes. • They have more marital difficulties with a greater number • of negative attitudes toward their spouse. • (Draper at al. 2007)

7. ‘Not-knowing’ Recovery from aphasia is hugely variable (Hillis and Heidler, 2002) Speech can be regained within the first few days, weeks or months after stroke or may take several years …how can carers and patients prepare for the future?

8. Impact of an unknown future The recovery road could be….. or Carers and patients want to be prepared for the right journey

9. In the words of patients “People can’t move forward until they know what’s happened to them and what the future might be” “If you don’t know what’s happened and what the possible outcomes are it’s not possible to move forward” With thanks to the stroke survivor presentations at the Stroke Associations UK Stroke Forum 2012

10. Needs of stroke survivors and carers • A clear understanding of what has happened • A long term plan • Range of possible outcomes: short and long-term To take ownership of their recovery

11. The role of the Health Professional: This way please… ??? The ‘tour guide’ for the journey What to expect – recovery outcome Realistic short and long term goals Support and advice

12. What guides Health Professionals? Initial severity? Lesion size? University? Experience? Research literature? Intuition? How confident are we that we can provide well-evidenced answers to carer’s questions about recovery?

13. The tightrope for Health Professionals False hope Despondency High expectations Lack of motivation for therapy Depression Realistic goals & appropriate support

14. Accurately predicting recovery: problem to date ? Speaking ability Years post stroke Lack of understanding of how lesion site influences language outcome & recovery…

15. therefore… Predicting the recovery journey for each patient is difficult A bit like predicting the weather in Britain based on the day before?!

16. Ingredients required To understand the relationship between lesion location and language recovery we need: Between-patient cross-sectional comparisons for large numbers of patients Accurate ways of defining & comparing the lesion Additional within-patient longitudinal comparisons to check accuracy of predictions

17. PLORAS project Predicting Language Outcome and Recovery After Stroke Aim = Create a clinical tool for patients, carers and clinicians To provide individualised predictions about recovery from aphasia after stroke, based on patient’s MRI brain image • Realistic goal-setting in therapy • Plan for a return to valued activities • Appropriate level and timing of support

18. Between-patient cross-sectional comparisons for large numbers of patients Over 500 stroke patients (and growing daily!) from Hospital UCLH & NHNN Community stroke groups, adverts, conferences etc

19. Procedure • Comprehensive Aphasia Test (CAT) • Cognitive screen • Language battery • Widely used in clinical practice • 2. MRI scan • Structural scan – 15 minutes

20. Accurate ways of defining & comparing the lesion High resolution 3D lesion images and advanced lesion identification software Voxel based analysis = improved accuracy

21. Meaningful interpretation of language scores Use composite language scores e.g. ‘speech production’ score considers: word repetition + sentence repetition + picture naming + picture description so that visual or auditory problems alone cannot account for impairment

22. Combine lesion information with language scores For hundreds of patients… Establish the relationship between: Exact lesion location Composite language score Time post stroke

23. Understanding the lesion - behaviour relationship enables predictions for patients 85% of patients with the same type of stroke damage as you recovered speech within 2 years

24. Examples of Findings NB ‘recovery’ defined as WNL scores on Comprehensive Aphasia Test

25. Key findings Accurate relationship between lesion site and recovery profile – tested at 98% accuracy Patients withspeech output difficulties persisting beyond 5 years had damage that severed both anterior and posterior segments of the superior longitudinal fasciculus

26. Key findings Non-aphasic range P A A&P Aphasic range Speech score PLORAS

27. Future work Continually expanding patient numbers • Coming to a hospital near you (hopefully!) via the Stroke Research Network Adjusting predictions for clinical scans: CT/ MRI Understanding influence of other factors • Age, motivation, amount of therapy Functional MRI scanning with recovered patients - To see use of alternative regions to damaged

28. Discussion 1: Your experiences Please help us by sharing your experiences of… What patients and carers have asked you about recovery What patients and carers have told you about recovery What kinds of answers you/others have given Difficulties associated with answering questions about recovery

29. Discussion 2 : Your opinion What are the implications (positive and negative) for: Patients Carers Health Professionals Of the availability of prediction information? What kind of information would you like to be able to give patients and carers? How might it influence your practice?

30. Discussion 3: Your advice Giving patients recovery predictions… Who? e.g. therapist, doctor, support worker When? e.g. first week, on discharge, at home How? e.g. face to face, self-access Where? e.g. whilst in hospital, in community As routine? Only if asked? In worst cases?

31. Taking Part • We are always recruiting patients for our research. • Inclusion criteria: • Have had a stroke. • Are able to have an MRI brain scan (we can tell you). • Are happy to have their language assessed. • Can travel to London (private transport negotiable). • We are interested in people who speak English only AND people who speak more than one language. PLORAS

32. Contact Details • Location: 12 Queen Square, London, WC1N 3BG • E-mail: ploras@ucl.ac.uk • Telephone: 020 7813 1538 • Add us as a friend on Facebook:Stroke Study • ‘Like’ our Facebook page:Aphasia Research at Wellcome Trust Centre for Neuro-imaging, UCL • Video: http://www.wellcome.ac.uk/News/2009/Features/WTX057690.htm • http://www.youtube.com/watch?v=Wn08mkGbGnQ

33. Photograph credits From Flickr – creative commons. Geodesic for ‘Road’ Rawmusic for motorway image Girlguides of Canada for ‘Guides Book 1’ The Other Martin Taylor for ‘Tightrope Walker’ SlawekPuklo for storm image Rhys Asplundh for ‘Sun & Clouds’ Doug 888 for ‘Richmond Snow’

34. References Brady, M., Kelly, H., Godwin, J., Enderby, P. 2012 Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 5. Draper, B., Bowring, G. Thompson, C., Van Heyst, J. Conroy, P., Thompson, J. Stress in caregivers of aphasic stroke patients: a randomised control trial. Clinical Rehabilitation, 2007 Feb; 21(2): 122-30 Hillis, A. and Heidler, J. 2002. Mechanisms of early aphasia recovery. Aphasiology, 16(9), 885-895 Price, C., Seghier, M., and Leff, A. 2010. Predicting language outcome and recovery after stroke: the PLORAS system. Nature Reviews Neurology 6, 202-210 . Seghier, M., Lee, H., Schofield, T., Ellis, C. and Price, C. 2008. Inter-subject variability in the use of two different neuronal networks for reading aloud familiar words. Neuroimage. 42(3-3): 1226–1236. Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. 1994.Patient preferences for stroke outcomes, Stroke. Sep;25(9):1721-5. Swinburn, K., Porter, G. and Howard, D. 2004. Comprehensive Aphasia Test. Hove: Psychology Press.

35. EXTRA SLIDES Slides from here on for use if time remaining after discussion…

36. PLORAS Aim 2 To further the theoretical understanding of aphasia recovery, so that the effect of therapy can be accurately tested PLORAS

37. Efficacy of impairment-based therapy • Currently there are problems proving efficacy of therapy. • Cochrane review (2012): • “…insufficient evidence to indicate the best approach to delivering speech and language therapy”. • None of the 39 studies in Cochrane review accounted for lesion site. PLORAS

38. Lesion information We believe lesion site is critical in determining recovery and response to impairment-based therapy. • To understand who will and will not respond to an intervention approach we first need to know: • Which brain regions are damaged? • How does damage affect language? • How does intervention influence the preserved pathways? PLORAS

39. Future implications speech score after intervention predicted by lesion Time post stroke Knowledge of typical recovery trajectory To provide a baseline against which to compare therapy Does a given therapy speed up this typical recovery? PLORAS

40. Recovery pathways Seghier et al. (2008) Example of how the effect of damage to one pathway depends on the integrity of other pathways. PLORAS