Aphasia Treatment Evidence-based Practice – The State of the Evidence

1. Aphasia TreatmentEvidence-based Practice – 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. Session Two Activity/Participation-based Treatment Treatment Delivery Emerging Treatment Techniques

3. Objectives • Identify evidence for activity/participation-based treatment techniques • Identify evidence for emerging treatment techniques • Identify considerations for successful treatment outcome

4. Activity/participation Based treatment techniques

5. 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)

7. Blackstone & Hunt Berg, 2006

8. 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)

9. Activity/Participation-based treatment techniques • Group treatment • Conversation participation • Treatment for caregivers or conversation partners • Personal narratives; scripts • AAC

10. Group Treatment

11. 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)

12. Evidence, ES and Conclusions Effect Sizes for Group vs. Individual Treatment --- RCTs --- Kelly, Brady, Enderby, 2010

13. Change Scores and Total Number of Participants for Studies of Group Treatment Change Score Salter, Teasell, Bhogal, Zettler & Foley (2010)

14. 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

15. 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 • 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

16. Conversation participation

17. 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

18. 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

19. 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

20. 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

21. Review of partner training studies • PWA – variable characteristics • Most lived independently • 4-178 MPO • Mild to moderate to severe aphasia • Comprehension and/or expression deficits • Partners • Primarily family members or usual partners • Approaches • Partner change was goal • Facilitate desirable behavior or inhibit undesirable behavior Turner & Whitworth , 2006; http://www.asha.org/members/reviews.aspx?id=7499

22. Outcomes • 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

23. Moderate (RCT) to limited (small studies) evidence supporting conversation and partner training • Considerations • Individual personalities of PWAs and partners • Conversational style Turner & Whitworth, 2006

24. 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

25. 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

26. Summary 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.

27. Treatment Influences

28. 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)

29. Activity/Participation ES for Outcome Measures for studies investigating intensity of treatment Impairment Cherney, Patterson, Raymer, Frymark & Schooling, 2008; Frymark, Cherney, Patterson & Raymer, 2010

30. 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

31. 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)

32. Neuronal Plasticity Principles of experience-dependent neural plasticity Time matters Salience matters Age matters Transference Interference • Use it or lose it • Use it and improve it • Specificity • Repetition matters • Intensity matters Kleim & Jones, 2008; Raymer et al., 2008; Raymer, Maher, Patterson & Cherney, 2007

33. 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

34. Summary Greater intensity may be more effective than lesser intensity. Individual variation for aphasia type, TPO and task. Errorless, reduced error and errorful treatment techniques are effective. Individual variation for aphasia type, TPO and task. Principles of neuronal plasticity positively influence treatment effectiveness.

35. Emerging Treatments

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

37. 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

38. Additional studies of drugs 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

39. 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, Holladn & 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

40. 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

41. 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

42. 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

43. Summary Inconsistent evidence supporting pharmacological treatment. Some favorable evidence in conjunction with behavioral 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.