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

1. Aphasia Treatment:Evidence-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

3. 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.

4. 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/

5. 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

6. 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

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

8. 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

9. ASHA Homepage > Research Tab > Evidence-based Practice

16. ANCDS & Evidence • Writing Groups • Practice Guidelines

19. 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

20. 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)

21. Aphasia Treatment

22. 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

23. Impairment-based treatment techniques

24. Impairment-based treatment techniques • Lexical retrieval • Constraint-Induced Language Treatment • Cueing Hierarchy • Semantic Feature Therapy • Reading • Writing • Complexity Account of Treatment Effectiveness

25. Lexical Retrieval

26. 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

27. Example 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

29. Example of semantic feature set

30. Cognitive neuropsychological processing model of word retrieval Kay, Lesser & Coltheart, 1992

31. 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)

32. 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

33. 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

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

35. Constraint Induced Language Therapy

36. 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?

37. 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

38. Model

39. Use dependent Cortical Reorganization Neuronal plasticity • Eventsthat 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)

40. CIMT example (Mark & Taub, 2004)

41. 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)

42. 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

43. 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

44. 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

45. 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.

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

47. Activity/participation Based treatment techniques

49. Blackstone & Hunt Berg, 2006

50. 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)