A Constraint-Induced Aphasia Therapy Success Story

A Constraint-Induced Aphasia Therapy Success Story
“
“
Very challenging but
you get used to it
after 2 or 3 days.
”
“
I get up. I have breakfast
with my sons. I slow down
a little and I appreciate
them a lot more.
“
I could achieve things
because I had speech.
“
”
I answer the phone now.
”
When I got out of CIAT
I could speak much faster.
”
Advanced Recovery
Rehabilitation Center
”
“
My speech has
(improved)
probably 500%
“
”
(CIAT) took my life
and turned it around.
”
“
Slowly but surely the speech came
together. Every week it improved.
”
Jennifer Brown, M.S., CCC-SLP
Advanced Recovery Rehabilitation Center
4419 Van Nuys Blvd, Suite 412
Sherman Oaks, CA 91403
818.386.1231
[email protected]
What is Constraint-Induced Therapy (CIT)?
History
• Used for more than a decade
by occupational therapists
• Developed by Edward Taub, Ph.D. at the University
of Alabama
• Goal is to regain the ability to use an arm or leg
affected by stroke or other brain injury
by overcoming learned non-use
• Physical constraint of unaffected side up to 90%
of waking hours
Principles of CIT
• Constraint of Compensatory Strategies
• Massed practice (6 hours daily)
• High repetitions
• Task specificity
CIT Research Results
• Significant improvement in 2-3 weeks
• Improvements are greater than those seen after the same number
of treatment hours spread over a longer time
• Improvements include increased amount of use, speed, quality of movement,
and self-perceived hand function
• Improvements can be maintained for at least 2 years
• Improvement can also be continued with program of home exercise
• According to 1 report, 70% of caregivers who quit their job to care for their
loved one were able to return to work after CIT
• Transcranial magnetic stimulation study indicates increase in cerebral cortex
representation of affected muscles
How do we apply these principles to treat aphasia?
Constraint-Induced Aphasia Therapy (CIAT)
Constraining Language
• No physical constraint is used
• Goal is to overcome learned non-use of spoken language
• Constraint consists of limiting use of compensatory strategies that reduce the need for spoken words
Principles of CIAT
• Constraint of compensatory strategies such as writing, gestures, avoidance, etc.
• Massed practice (3 hours daily)
• High repetitions
• Task specificity
Current Research
• 2 studies completed in Germany
• 2 studies ongoing or recently completed in US
• 1 ongoing study in UK
• Results
-Available from 2 German studies
-Both found that clients were able to make statistically significant improvements
over a short duration of treatment
-Improvements were greater than those achieved with the same number
of treatment hours spread over a longer time
-Improvements were maintained over 6 months
-Increased language stimulation through home assignments resulted in even greater improvements
Case Study
EM
! 43 year-old male
! Business owner
! CVA 1 year prior to CIAT
! Resulting Broca’s aphasia
! Received SLP services using a traditional
schedule for 1 year prior to CIAT
! Limited results reported
! Unable to work in any capacity
following CVA
! Reported feeling severely limited in his
ability to parent his 3 children
Methods
! Treatment provided 3.5 hours daily
! Activities included
• Confrontation naming
• Games requiring verbal response
! Activities were graded over the course
of treatment to maintain an extremely
challenging set of tasks
! No time limit for providing correct response
! Minimal cueing provided when EM expressed that
he was “stuck” and could make no further
progress toward a correct response
! 2-3 hours of homework assigned each night
! At discharge
• A home program was provided
• Education provided related to ways to make
everyday activities into language stimulating tasks
• Instructed to return to work in any capacity he
felt able and to attempt linguistically challenging
activities everyday regardless of success or failure
Results
Following18 treatments (63 treatment hours)
improvements were measured using the Boston
Diagnostic Aphasia Examination and Boston Naming
Test and were as follows:
Pre-CIAT
%-ile
Aphasia Severity Rating
Overall Fluency Rating
Conversation and Expository Speech Rating
Articulation Rating
Overall Repetition Rating
Overall Naming Rating
Paraphasia Rating
Boston Naming Test
Post-CIAT
%-ile
40th 80th
43rd 70th
80th 100th
40th 50th
70th 95th
60th 90th
60th 85th
Pre-CIAT
Post-CIAT
Correct
Responses
Correct
Responses
31
51
Other non-standardized measurements also
yielded improvements:
Confrontation naming using actual objects
increased from 44% accurate with
maximum increased time required to 100%
accurate with minimally increased time
required and with moderate environmental
distraction
Simple requests using full sentences
increased from 50% adequate with 4-5
word script provided to 100% accurate
independently using moderately to
highly complex categorization and word
finding skills (i.e. for Go Fish, scripted
request initially was, “Do you have a
seven?” At the end of treatment a
successful independently worded request
would have been, “Do you have the
number that comes after six and before
eight?” or “Do you have the number that
equals fifteen minus eight?”).
Overall communicative effectiveness
increased from a subjective rating of 55%
for minimally to moderately complex
content to 98% for moderately to highly
complex content in a moderately stressful
situation.
Length of Conversation (in minutes)
120min
Overall Communicative Effectiveness
100%
90%
100min
80%
70%
80min
60%
120
60min
120
98%
50%
98%
98%
40%
40min
30%
20%
20min
2
0min
pre-CIAT
15
post-CIAT
35%
10%
12 months
post-CIAT
18 months
post-CIAT
0%
pre-CIAT
Speed of Communication
100%
90%
90%
80%
80%
95%
50%
60%
50%
85%
70%
40%
30%
20%
20%
20%
pre-CIAT
post-CIAT
12 months
post-CIAT
18 months
post-CIAT
100%
80%
40%
Confrontation Naming
Go Fish Requests
Go Fish Responses
20%
Overall Communicative Effectiveness
(in easy to mod complex situations)
9/
04
2/
11
/0
4
2/
13
/0
4
2/
15
/0
4
2/
17
/0
4
2/
19
/0
4
2/
21
/0
4
2/
23
/0
4
2/
25
/0
4
2/
27
/0
4
2/
29
/0
3/ 4
2/
04
3/
4/
04
0%
2/
90%
95%
50%
10%
Accuracy with Treatment Activities
60%
75%
40%
30%
0%
18 months
post-CIAT
70%
60%
10%
12 months
post-CIAT
Intelligibility
100%
70%
post-CIAT
0%
pre-CIAT
post-CIAT
12 months
post-CIAT
18 months
post-CIAT
EM Today
! Back at work full time
! Able to make presentations and proposals
to clients for high profile entertainment
industry events
! EM reports an increased role in parenting
his children
! EM’s spouse reports re-emerging pre-morbid
personality traits and willingness and ability
to interact with family and business associates
Language Comparison
Cookie Theft Picture
Pre-CIAT: “The mom is running
the water. The tookie tar is being
tapped. But the kid is falling off the
circle (10 second delay) stool. This
little girl is waiting for a cookie jar.
Waiting for a cookie. There are
(unintelligible). The round. There’s a
sink and the water uhm. (20
second delay) If there was, if there
was if (unintelligible) some little
(unintelligible) towel. And they’d
be sitting on a towel.”
Immediately post-CIAT: “The little
girl on the stool is waiting for a
cookie. More to the right the little
boy’s falling out. Move further to
the right. The mother’s stepping in,
uh, dirty dishwasher, uhm. Not
dishwasher. Go up a little. The
dishwasher is all over the place.
The uh, (10 second delay) she’s uh,
you need a towel underneath
those (cups). Uh (5 second delay)
she should know what the warm
fluid is and put it out with the (3
second delay) and that’s it.”
12 months post-CIAT: “The kid’s
in the cookie jar but he’s falling off
the stool. The girl has her right
hand over her face and she has the
left hand up for a cookie. Next you
see the momma wiping the dishes
trying to dry them. Meanwhile, she
doesn’t see the water’s on and
overflowing the sink and she
doesn’t notice the kid falling off
the chair. Her foot is also in the
water.
Question by interviewer: “What do you do for a living?”
Pre-CIAT: “I own my company. I
own a (20 second pause). We do
lights and sound and
(unintelligible), and audio. We did
parts of (unintelligible) Grammy
Awards last night. We did parts of
uh, (30 second pause). Have you
heard of the ladies who are
(unintelligible)? They are from New
York. They do one week worth of
show biz, no wait, fashion biz. This
week they are doing
(unintelligible).”
Immediately post-CIAT: “(Joking)
I got fired. It's wonderful. (MM)
fired me. Ha ha. My job is as
executive of a production
company. We go out and do lights,
sound, and stage things and it's my
job to go out and get things done
without too many bumps along
the way.”
“
18 months post-CIAT: “We started
with 2 lonely turntables and then 2
cassette decks, 2 amplifiers, 2, uhm,
4 speakers and a man. It was 1986.
So we grew from that nothing sort
of thing to an actual business
that's run by other people and uh
we now do lighting and staging
and video and we hire all the same
people for all the good work. We
do about 400 shows per year.”
Everytime I get
a new word right,
I think about (CIAT).
”
Advanced Recovery
Rehabilitation Center
References and Additional Reading
Aten, J. (1994). Functional communication treatment. In R. Chapey (Ed.), Language intervention strategies in adult
aphasia (3rd ed.) (pp. 292-303). Baltimore, MD: Williams & Wilkins.
Bhogal, S.K., Teasell, R., and Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke. 34, 987.
Davis, G. and Wilcox, M. (1981). Incorporating parameters of natural conversation in aphasia treatment. In R. Chapey
(Ed.), Language intervention strategies in adult aphasia. Baltimore, MD: Williams, & Wilkins.
Duffy, J. R., (1995). Motor speech disorders: Substrates, diagnosis, and management. St. Louis, MO: Mosby-Year Book, Inc.
Goodglass, H., and Kaplan, E. (1983a). Boston diagnostic aphasia examination. Malvern, PA: Lea & Febinger.
Goodglass, H., and Kaplan, E. (1983a). Boston naming test. Malvern, PA: Lea & Febinger.
Horner, J., Loverso, F., and Rothi, L. (1994) Models of aphasia treatment. In R. Chapey (Ed.), Language intervention
strategies in adult aphasia (3rd ed.) (pp. 135-145). Baltimore, MD: Williams & Wilkins.
Leipert, J., Bauder, H., Miltner, W.H.R., Taub, E., and Weiller, C. (2000). Treatment-induced cortical reorganization after
stroke in humans. Stroke. 31, 1210-1216.
Liepert, J., Miltner, W.H.R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., and Weiller, C. (1998). Motor cortex plasticity
during constraint-induced movement therapy in stroke patients. Neuroscience Letters. 250, 5-8.
Levy, C.E., Nichols, D.S., Schmalbrock, P.M., Keller, P., and Charkeres, D.W. (2001). Functional MRI evidence of cortical
reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. American Journal
of Physical Medicine and Rehabilitation. 80, 4-12.
Lubinski, R. (1994). Environmental systems approach to adult aphasia. In R. Chapey (Ed.), Language intervention
strategies in adult aphasia (3rd ed.) (pp. 267-291). Baltimore, MD: Williams & Wilkins.
McLaughlin, M. and Cody, M. (1982). Awkward silences: Behavioural antecedents and consequences of the
conversational lapse. Human Communication Research. 8, 299-316, 1982.
1
Meinzer M,Djundja D,Barthel G,et al.Long-term stability of improved
language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke. 2005;36(7):1462-6
Musso, M., Weiller, C., Kiebel, S., Muller, S., Lulau, P., and Rijntjes, M.. (1999). Training-induced plasticity in aphasia. Brain.
122, 1781-1790.
2
Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., and Taub, E. (2001). Constraint-induced
therapy of chronic aphasia after stroke. Stroke. 32, 1621.
Small, S.L. (2000). The future of aphasia treatment. Brain and Language. 71, 227-232.
Taub, E., Uswatte, G., and Pidikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques with
broad application to physical rehabilitation: A clinical review. Journal of Rehabilitation Research and Development. 36,
237-251.
Todman, J., Alm, N. (2003) Modelling conversational pragmatics in communication aids. Journal of Pragmatics. 35, 523538.
Wertz, R.T., LaPointe, L.L, and Rosenbeck, J.C. (1984). Apraxia of speech in adults: The disorder and its management. New
York, NY: Grune& Stratton.
Wolf, S. L., Winstein, C. J., Miller, J. P., et al. Effect of constraint-induced movement therapy on upper extremity function 3
to 9 months after stroke. Journal of the American Medical Association. 2006;296:2095-2104.