A Constraint-Induced Aphasia Therapy Success Story
Transcription
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.