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
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 EvidenceBased Practice (N-CEP)
– http://www.asha.org/Members/
ebp/default/
•
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/
ASHA Division 2
– http://www.asha.org/members/
divs/div_2.htm
ANCDS
– www.ancds.org
SORTing the Evidence
By 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
RCT Effect Size favoring treatment for
naming outcome measure
Treated items
Naming
Naming
Task Specific v General
Individual v Group
PICA
AAT
SLP v Volunteer
PICA
AAT
Effect Size
Conventional v Functional
AAT
PALPA
Treatment v Social Support
Word Fluency
Object Naming Test
Treatment v No Treatment
WAB Naming
BNT
0
2
4
6
8
10
12
14
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 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)
Studies included in two reviews
Cherney, Patterson, Raymer, Frymark, Schooling (2008, 2010)
CILT
Berthier et al., 2009
Breier et al., 2006, 2007,
2009
Meinzer et al., 2004, 2005,
2006, 2007a, 2007b,
2008, 2009
Faroqi-Shah et al., 2009
Pulvermuller et al., 2001,
2005
Goral & Kempler, 2009
Richter et al., 2008
Kirness & Maher, 2010
Szaflarski et al., 2008
Maher et al., 2006
Intensity
Bakheit, et al., 2007
Hinckley & Craig, 1993
Basso & Caporali, 2001
Puvermuller et al., 2001
Denes et al., 1996
Ramsberger & Marie,
2007
Harnish et al., 2008
Hinckley & Carr, 2005
Raymer et al., 2006
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
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.
Impairment
Activity Participation
Effect Sizes favoring Constraint Induced Language Treatment for
Impairment and Activity/Participation outcome measures
Total # words
Tense diversity
Tense accuracy
Proportion of well-formed sentences
Proportion of sentences
Memantine+CIAT prepost (CAL)
Different root words
# Utterances
AATSpontaneous Speech
Severity
Repetition
Naming
Memantine+CIAT v Placebo+CIAT
Memantine+CIAT prepost (Naming)
LCI
Comprehension
BNT
BDAE-3 VE
BDAE-3 AC
ANT
ANELT SC
ANELT AC
AAT TT
AAT TT
AAT TT
AAT Profile Therapist trained
AAT Profile Relative trained
AAT Profile
AAT Profile
WAB AQ
-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)
Evidence, ES and Conclusions
Effect Sizes for Group vs. Individual Treatment
--- RCTs --WAB AQ
WAB AQ
Token Test
Token Test
PICA Verbal Subtest
PICA Overall
PICA Graphic
PICA Gestural Subtest
AAT Repetition Subtest
AAT Overall
AAT Naming Subtest
AAT Comprehension Subtest
-5.1
-0.1
4.9
9.9
14.9
19.9
24.9
29.9
34.9
39.9
Kelly, Brady, Enderby, 2010
Change Scores and Total Number of Participants for
Studies of Group Treatment
80
70
Change Score
60
50
40
30
Participants showing positive change
Number of participants
20
10
0
Salter, Teasell, Bhogal, Zettler & Foley (2010)
• 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)
Activity/Participation
Impairment
ES for
Outcome
Measures for
studies
investigating
intensity of
treatment
Cherney, Patterson, Raymer, Frymark
& Schooling, 2008;
Frymark, Cherney, Patterson & Raymer, 2010
Content Units
Content Analysis
Communication Activity Log-SLPs2.64
Communication Activity Log-Patients
Catalogue order-written-quiet
Catalogue order-written-dual task
Catalogue order-oral-quiet
Catalogue order-oral-dual task
CADL-2
Word/Picture Verification-Maintenance-lo
Word/Picture Verification-Maintenance-hi
Word/Picture Verification-Acquisition-lo
Word/Picture Verification-Acquisition-hi
WAB AQ
WAB AQ
WAB AQ
WAB AQ
Picture Naming-Maintenance-lo
Picture Naming-Maintenance-hi
Picture Naming-Acquisition-lo
Picture Naming-Acquisition-hi
Naming
Naming
Naming
Naming
Naming
Naming
Naming
Fable retell-words
Fable retell-utterances
Fable retell-TTR
Fable retell-MLU
AAT Naming
AAT Langugae Comprehension
-1.2
0.8
2.8
4.8
6.8
8.8
10.8
12.8
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 Plasticity
Principles of experience-dependent neural plasticity
• Use it or lose it
• Time matters
• Use it and improve it
• Salience matters
• Specificity
• Age matters
• Repetition matters
• Transference
• Intensity matters
• 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
Summary
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).
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.