1. Using Neuroscience to understand aphasia recovery UCL INSTITUTE OF NEUROLOGY Shedding some light into the darkness!

2. UCL INSTITUTE OF NEUROLOGY Who are we? Louise Lim Research Associate and Speech & Language Therapist Johanna Rae Research Assistant (Bilingual) and Speech & Language Therapist From: University College London, Institute of Neurology, Wellcome Trust Centre for Neuroimaging

3. UCL INSTITUTE OF NEUROLOGY The patient-facing team Prof Cathy Price Dr Alex Leff Louise Lim Zula Haigh Rachel Browne Johanna Rae PLORAS

4. UCL INSTITUTE OF NEUROLOGY Aphasia An acquired language disorder following brain injury. Affects a third of stroke survivors Can involve understanding language, speaking, reading and writing One of the most feared outcomes after stroke (Soloman, Glick, Russo, Lee and Schulman, 1994)

5. UCL INSTITUTE OF NEUROLOGY Impact of Aphasia on Carers Communication difficulties due to aphasia following stroke are particularly difficult for caregivers… isolation role-change identity stress depression helplessness

6. UCL INSTITUTE OF NEUROLOGY From the literature Most studies conclude that: Caregivers of aphasic stroke patients are more stressed, with symptoms of depression, loneliness and other emotional problems than caregivers of non-aphasic stroke patients. Their (carers of people with aphasia’s) overall adjustment to the stroke is poorer and they experience greater role changes. They have more marital difficulties with a greater number of negative attitudes toward their spouse. (Draper at al. 2007)

7. UCL INSTITUTE OF NEUROLOGY ‘Not-knowing’ Recovery from aphasia is hugely variable (Hillis and Heidler, 2002) Speech can be regained within the first few days, weeks or months after stroke or may take several years …how can carers and patients prepare for the future?

8. UCL INSTITUTE OF NEUROLOGY Impact of an unknown future The recovery road could be….. Carers and patients want to be prepared for the right journey or

9. UCL INSTITUTE OF NEUROLOGY In the words of patients “People can’t move forward until they know what’s happened to them and what the future might be” “If you don’t know what’s happened and what the possible outcomes are it’s not possible to move forward” With thanks to the stroke survivor presentations at the Stroke Associations UK Stroke Forum 2012

10. UCL INSTITUTE OF NEUROLOGY Needs of stroke survivors and carers A clear understanding of what has happened A long term plan Range of possible outcomes: short and long-term To take ownership of their recovery

11. UCL INSTITUTE OF NEUROLOGY The role of the Health Professional: The ‘tour guide’ for the journey What to expect – recovery outcome Realistic short and long term goals Support and advice This way please… ???

12. UCL INSTITUTE OF NEUROLOGY What guides Health Professionals? Initial severity? Lesion size? University? Experience? Research literature? Intuition? How confident are we that we can provide well- evidenced answers to carer’s questions about recovery?

13. UCL INSTITUTE OF NEUROLOGY The tightrope for Health Professionals False hope High expectations Despondency Lack of motivation for therapy Realistic goals & appropriate support Depression

14. UCL INSTITUTE OF NEUROLOGY Accurately predicting recovery: problem to date Lack of understanding of how lesion site influences language outcome & recovery… Years post stroke Speaking ability

15. UCL INSTITUTE OF NEUROLOGY therefore… Predicting the recovery journey for each patient is difficult A bit like predicting the weather in Britain based on the day before?!

16. UCL INSTITUTE OF NEUROLOGY Ingredients required To understand the relationship between lesion location and language recovery we need: Between-patient cross-sectional comparisons for large numbers of patients Accurate ways of defining & comparing the lesion Additional within-patient longitudinal comparisons to check accuracy of predictions

17. UCL INSTITUTE OF NEUROLOGY PLORAS project Predicting Language Outcome and Recovery After Stroke Aim = Create a clinical tool for patients, carers and clinicians To provide individualised predictions about recovery from aphasia after stroke, based on patient’s MRI brain image  Realistic goal-setting in therapy  Plan for a return to valued activities  Appropriate level and timing of support

18. UCL INSTITUTE OF NEUROLOGY Between-patient cross-sectional comparisons for large numbers of patients Over 500 stroke patients (and growing daily!) from Hospital UCLH & NHNN Community stroke groups, adverts, conferences etc

19. UCL INSTITUTE OF NEUROLOGY Procedure 1.Comprehensive Aphasia Test (CAT) Cognitive screen Language battery Widely used in clinical practice 2. MRI scan Structural scan – 15 minutes

20. UCL INSTITUTE OF NEUROLOGY Accurate ways of defining & comparing the lesion High resolution 3D lesion images and advanced lesion identification software Voxel based analysis = improved accuracy

21. UCL INSTITUTE OF NEUROLOGY Meaningful interpretation of language scores Use composite language scores e.g. ‘speech production’ score considers: word repetition + sentence repetition + picture naming + picture description so that visual or auditory problems alone cannot account for impairment

22. UCL INSTITUTE OF NEUROLOGY Combine lesion information with language scores For hundreds of patients… Establish the relationship between: Exact lesion location Composite language score Time post stroke

23. UCL INSTITUTE OF NEUROLOGY Understanding the lesion - behaviour relationship enables predictions for patients 85% of patients with the same type of stroke damage as you recovered speech within 2 years

24. UCL INSTITUTE OF NEUROLOGY NB ‘recovery’ defined as WNL scores on Comprehensive Aphasia Test Examples of Findings

25. UCL INSTITUTE OF NEUROLOGY Key findings Accurate relationship between lesion site and recovery profile – tested at 98% accuracy Patients with speech output difficulties persisting beyond 5 years had damage that severed both anterior and posterior segments of the superior longitudinal fasciculus

26. UCL INSTITUTE OF NEUROLOGY Key findings Speech score A Aphasic range A&P Non-aphasic range P PLORAS

27. UCL INSTITUTE OF NEUROLOGY Future work Continually expanding patient numbers -Coming to a hospital near you (hopefully!) via the Stroke Research Network Adjusting predictions for clinical scans: CT/ MRI Understanding influence of other factors -Age, motivation, amount of therapy Functional MRI scanning with recovered patients - To see use of alternative regions to damaged

28. UCL INSTITUTE OF NEUROLOGY Discussion 1: Your experiences Please help us by sharing your experiences of… What patients and carers have asked you about recovery What patients and carers have told you about recovery What kinds of answers you/others have given Difficulties associated with answering questions about recovery

29. UCL INSTITUTE OF NEUROLOGY Discussion 2 : Your opinion What are the implications (positive and negative) for: Patients Carers Health Professionals Of the availability of prediction information? What kind of information would you like to be able to give patients and carers? How might it influence your practice?

30. UCL INSTITUTE OF NEUROLOGY Discussion 3: Your advice Giving patients recovery predictions… Who? e.g. therapist, doctor, support worker When? e.g. first week, on discharge, at home How? e.g. face to face, self-access Where? e.g. whilst in hospital, in community As routine? Only if asked? In worst cases?

31. UCL INSTITUTE OF NEUROLOGY Taking Part We are always recruiting patients for our research. Inclusion criteria: Have had a stroke. Are able to have an MRI brain scan (we can tell you). Are happy to have their language assessed. Can travel to London (private transport negotiable). We are interested in people who speak English only AND people who speak more than one language. PLORAS

32. UCL INSTITUTE OF NEUROLOGY Contact Details Location: 12 Queen Square, London, WC1N 3BG E-mail: ploras@ucl.ac.uk Telephone: 020 7813 1538 Add us as a friend on Facebook: Stroke StudyStroke Study ‘Like’ our Facebook page: Aphasia Research at Wellcome Trust Centre for Neuro-imaging, UCLAphasia Research at Wellcome Trust Centre for Neuro-imaging, UCL Video: http://www.wellcome.ac.uk/News/2009/Features/WTX05769 0.htm http://www.youtube.com/watch?v=Wn08mkGbGnQ

33. UCL INSTITUTE OF NEUROLOGY Photograph credits From Flickr – creative commons. Geodesic for ‘Road’ Rawmusic for motorway image Girlguides of Canada for ‘Guides Book 1’ The Other Martin Taylor for ‘Tightrope Walker’ Slawek Puklo for storm image Rhys Asplundh for ‘Sun & Clouds’ Doug 888 for ‘Richmond Snow’

34. UCL INSTITUTE OF NEUROLOGY References Brady, M., Kelly, H., Godwin, J., Enderby, P. 2012 Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 5. Draper, B., Bowring, G. Thompson, C., Van Heyst, J. Conroy, P., Thompson, J. Stress in caregivers of aphasic stroke patients: a randomised control trial. Clinical Rehabilitation, 2007 Feb; 21(2): 122-30 Hillis, A. and Heidler, J. 2002. Mechanisms of early aphasia recovery. Aphasiology, 16(9), 885-895 Price, C., Seghier, M., and Leff, A. 2010. Predicting language outcome and recovery after stroke: the PLORAS system. Nature Reviews Neurology 6, 202- 210. Seghier, M., Lee, H., Schofield, T., Ellis, C. and Price, C. 2008. Inter-subject variability in the use of two different neuronal networks for reading aloud familiar words. Neuroimage. 42(3-3): 1226–1236. Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. 1994.Patient preferences for stroke outcomes, Stroke. Sep;25(9):1721-5. Swinburn, K., Porter, G. and Howard, D. 2004. Comprehensive Aphasia Test. Hove: Psychology Press.

35. UCL INSTITUTE OF NEUROLOGY EXTRA SLIDES Slides from here on for use if time remaining after discussion…

36. UCL INSTITUTE OF NEUROLOGY PLORAS Aim 2 To further the theoretical understanding of aphasia recovery, so that the effect of therapy can be accurately tested PLORAS

37. UCL INSTITUTE OF NEUROLOGY Efficacy of impairment-based therapy Currently there are problems proving efficacy of therapy. Cochrane review (2012): ‒ “…insufficient evidence to indicate the best approach to delivering speech and language therapy”. ‒ None of the 39 studies in Cochrane review accounted for lesion site. PLORAS

38. UCL INSTITUTE OF NEUROLOGY Lesion information We believe lesion site is critical in determining recovery and response to impairment-based therapy. To understand who will and will not respond to an intervention approach we first need to know: −Which brain regions are damaged? −How does damage affect language? −How does intervention influence the preserved pathways? PLORAS

39. UCL INSTITUTE OF NEUROLOGY Future implications Knowledge of typical recovery trajectory To provide a baseline against which to compare therapy Does a given therapy speed up this typical recovery? after intervention predicted by lesion speech score Time post stroke PLORAS

40. UCL INSTITUTE OF NEUROLOGY Recovery pathways Example of how the effect of damage to one pathway depends on the integrity of other pathways. Damage toRecovery pathway White pathway Red pathway White pathway Red and white pathways ? Seghier et al. (2008) PLORAS