Aphasia Treatment
Evidence-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
Session One
Evidence-based Practice
Aphasia Treatment
Impairment-based Treatment
Objectives
– List principles of Evidence-based Practice
– Identify a system for evaluating strength of
evidence
– Identify evidence for impairment-based treatment
techniques
2
Neurophysiology and Neurogenic
Speech and Language Disorders
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Academy of Neurologic Communication
Disorders & Sciences
The purposes are professional, clinical,
educational, scientific and charitable, and
are ultimately to encourage the highest
quality of life for individuals with neurologic
communication disorders.
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)
EBP components
The goal of EBP is the integration of: (a) clinical expertise, (b) best current evidence,
and (c) client values to provide high-quality services reflecting the interests, values,
needs, and choices of the individuals we serve.
http://www.asha.org/members/ebp/intro.htm
Finding the evidence
• ASHA National Center
for Evidence-Based
Practice (N-CEP)
– http://www.asha.org/Membe
rs/ebp/default/
• ASHA Division 2
– http://www.asha.org/membe
rs/divs/div_2.htm
• ANCDS
– www.ancds.org
• Agency for Healthcare
Research and Quality
– http://www.guideline.gov/
• The Cochrane
Collaboration
– http://www.cochrane.org/
• Centre for EvidenceBased Medicine
– http://www.cebm.net/
SORTing the Evidence
• Patient-oriented evidence measures outcomes that
matter to patients: morbidity, mortality, symptom
improvement, cost reduction, and quality of life.
• Disease-oriented evidence measures intermediate,
physiologic, or surrogate end points that may or may
not reflect improvements in patient outcomes (e.g.,
blood pressure, blood chemistry, physiologic
function, pathologic findings).
Grading the Evidence
Strength of Recommendation
The strength (or grade) of a recommendation for
clinical practice is based on a body of evidence
(typically more than one study). This approach takes
into account the level of evidence of individual
studies; the type of outcomes measured by these
studies (patient-oriented or disease-oriented); the
number, consistency, and coherence of the evidence
as a whole; and the relationship between benefits,
harms, and costs.
Ebell, Siwek, Weiss, Woolf, Susman, Ewigman & Bowman (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)
Outcome Measures
WHO International Classification of Functioning, Disability and Health
http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf
Impairment
Activity/Participation
Contextual factors
Pre- and Post-treatment Measures
Daily Probes
• Impairment-based outcome measures
– Standardized tests (i.e. WAB, BDAE, BNT)
– Lexical retrieval measures (i.e. # items named)
– Sentence production (i.e. sentence form SVO)
• Activity/Participation-based outcomes
– Communication skills (i.e. CETI Lomas et al. 1989 )
– Correct Information Units (i.e. CIUs Brookshire & Nicholas, 1993)
– Content (i.e. Content Units Yorkston & Beukelman, 1980)
– Communication partner rating
Effect size
• Many methods of calculation
• Most common method references means and
variability
– 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)
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
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
ANCDS & Evidence
• Writing Groups
• Practice Guidelines
KSHA 2010 Aphasia Treatment
KSHA 2010 Aphasia Treatment
Cautions
• Study quality
Strength of evidence
Practice Guidelines
• Methodology is often inconsistent
• Seeking the best evidence may result in lack of
support for a treatment without evidence
• Consider all EBP components in treatment
decisions
APHASIA TREATMENT
Aphasia language treatment
• Treatment is beneficial
– Kelly, Brady & Enderby (2009)
• http://web.ebscohost.com/ehost/pdfviewer/pdfviewer
?vid=8&hid=10&sid=c62a94a6-f882-4088-973a0099791a0b6b%40sessionmgr112
– Robey (1998, 1994)
– Salter, Teasell, Bhogal, Zettler, Foley (2009)
• 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
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
Example of semantic feature set
Cognitive neuropsychological processing model of word retrieval
Kay, Lesser & Coltheart, 1992
Treatment examples
• Stimulation-facilitation (Schuell, 1965)
• Cues
– Cueing hierarchy (Linebaugh & Lehner; 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)
CILT questions
For stroke-induced chronic aphasia, what is the influence of constraintinduced language therapy on measures of language impairment?
For stroke-induced chronic aphasia, what is the influence of constraintinduced language therapy on measures of communication
activity/participation?
For stroke-induced acute aphasia, what is the influence of constraint-induced
language therapy on measures of language impairment?
For stroke-induced acute aphasia, what is the influence of constraint-induced
language therapy on measures of communication activity/participation?
For stroke-induced chronic aphasia, what treatment outcomes are
maintained following constraint-induced language therapy?
Cherney, Patterson, Raymer, Frymark, Schooling (2008)
Evidence, ES & Conclusions
• Systematic Review 2008
• 5 studies with 90 participants
- Language impairment measures: CILT resulted in positive
changes; primarily nonfluent patients
- Communication activity/participation measures: CILT
reported to lead to positive changes, though no effect sizes
calculable
- Data available only for chronic aphasia. No data speak to
the effects of CILT in acute aphasia.
- Maintenance of CILT effects: reported to lead to positive
changes; no effect sizes calculable
Cherney, Patterson, Raymer, Frymark, Schooling (2008)
• CILT Update 2010
• 14 studies with 230 participants
- Language impairment measures: CILT resulted in positive
changes
- Communication activity/participation measures: CILT
resulted in positive changes
- Data available for acute and chronic aphasia. CILT resulted
in positive changes
- Maintenance of CILT effects: CILT resulted in positive
changes
• However …
– Preliminary evidence; exploratory in nature
– Varying protocols and tasks
Frymark, Cherney, Patterson & Raymer (2010)
Activity Participation
Impairment
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
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.