Janine Mullay and Claire Layfield (Group Co-Leaders) Lyndsey Nickels - Academic Member

Does Constraint Induced Therapy Improve Communication Outcomes in People with Aphasia?

 Originated from CI movement therapy used by Physios and Occupational Therapists  Removes compensatory strategies  Requires the use of verbal output  Intensive over short period of time  Conducted within small group settings

 Effectiveness of CILT was reviewed in 2006 EBP Language group  Topic has generated more research and discussion since 2006  Results from 2006 EBP review were inconclusive  Aim of 2010 EBP group was to (i) evaluate new evidence (ii) provide a resource for EBP website for SP access

 Selection criteria = treatment effects of CILT, aphasia post stroke and chronic aphasia (> 6 months post stroke)  12 possible articles were found  10 out of 12 answered our clinical question and were included in the CAT

 Overall results indicate that CILT leads to improved language outcomes  9/10 studies reported significantly improved language outcomes on standardised measures  1/10 demonstrated a trend indicating improved outcomes without statistical significance

 Although results typically indicated that CILT lead to improved language outcomes only a few studies investigated generalised language outcomes  Modified versions targeting generalisation and agrammatism

 What is the mechanism behind the improvements???  Constraint vs intensive other treatments

 Cherney, LR, Patterson,JP, RAymer, A, Frymark,T, Schooling, T. (2008). Evidence based Systematic Review: effects of intensity of treatment and constraint induced language therapy for Individuals with stroke induced Aphasia. Journal of Speech, Language and Hearing Research.51(5):  CLINICAL BOTTOM LINE: Although moderate evidence exists for more intensive treatment and CILT for individuals with stroke induced aphasia, the results of this systematic review should be interpreted conservatively and used in conjunction with clinical expertise and clients’ values.

 Pulvermuller, F; Neininger, B; Elbert, T; Mohr, B; Rockstroh, B; Koebbel, P; Taub, E (2001) Constraint-induced therapy of chronic aphasia after stroke. In Stroke, Vol 32; pp  CLINICAL BOTTOM LINE: Massed-practice constraint induced therapy performed intensely over a short period of time with patients with chronic aphasia resulted in improved performance on standardised assessment/questionnaire. In comparing with “conventional” therapy, it is difficult to conclude whether constraint induced therapy was more effective as the treatments were not administered in the same frequency.

 Meinzer M. Djundja D. Barthel G. Elbert T. Rockstroh B. Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke. 36(7):1464-6, 2005 Jul.  CLINICAL BOTTOM LINE: Massed-practice constraint- induced therapy performed intensely over a short period of time with patients with chronic aphasia resulted in improved performance on standardised assessment and questionnaires regarding quantity/quality of communication. Unable to assess effectiveness from other more conventional therapies

 Faroqi-Shah Y, Virion CR (2009) Constraint-induced language therapy for aggrammaticality constraints. Aphasiology. 23 (7-8);  CLINICAL BOTTOM LINE: Constraint induced language therapy (with or without grammatical shaping) may lead to improved performance in therapy tasks for patients with Broca’s Aphasia, but may not lead to improvement in overall language severity measures or in conversational & narrative speech samples.

 Maher, L., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S., Pingel, K., Holland, A., & Gonsalez Rothi, L. (2006). A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12 (1),  CLINICAL BOTTOM LINE: Constraint induced language therapy can improve communication outcomes based on measures of the WAB (Aphasia Quotient), Boston Naming Test, Action Naming Test and narrative discourse, in people with Aphasia. However, there were nil significant differences between CILT and PACE therapy.

 Meinzer, M., Streiftau, S., & Rockstroh, B. (2007). Intensive language training in the rehabilitation of chronic aphasia: Efficient training by laypersons. Journal of the International Neuropsychological Society, 13(5),  CLINICAL BOTTOM LINE: CIAT resulted in positive language outcomes for all individuals with chronic aphasia and can be administered by trained laypersons with results comparable to that of experienced therapists.

 Virion, C. R. (2008). “Go aphasia!”: Examining the efficacy of constraint-induced language therapy for individuals with agrammatic aphasia (Master’s Thesis). Available from Digital Repository at the University of Maryland. (Identifier No. 8611).  CLINICAL BOTTOM LINE: Constraint induced therapy may not improve language outcomes for people with agrammatic aphasia. Modifying constraint induced therapy in its original form to include a grammatical constraint may increase its efficacy in this population.

 Goral M & Kempler D (2009). Training verb production in communicative context: Evidence from a person with chronic non-fluent aphasia. Aphasiology, 23 (12),  CLINICAL BOTTOM LINE: Constraint Induced Language Therapy for the verbal production of verbs is successful in a person with chronic non-fluent aphasia, and improves perceptions of one’s communicative competence overall.

 Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM, Neils-Strunjas J, Newmeyer A, Reichhardt R. (2008) Constraint Induced Aphasia Therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Medical Science Monitor, 14 (5) 243 – 250.  CLINICAL BOTTOM LINE: A customised, intensive (1 week), structured Constraint Induced Aphasia Therapy approach may improve listening skills and story retell ability

 Breier, J.I. Juranek, L. M. Maher, S. Schmadeke, D. Men, A. C. Papanicololaou (2009). Behavioural and Neurophysiologic Response to Therapy for Chronic Aphasia. Arch Phys Med Rehabilitation. 90:  CLINICAL BOTTOM LINE : Although the Right hemisphere may support recovery of language function in response to CILT, this recovery may not be stable and some participation of perilesional areas of the left hemisphere may be necessary for a stable behaviour response

 Amanda Osbourne presented results from the CILT group she ran in 2010 at the Aphasiology Symposium Clients were recruited from two different metropolitan outpatient speech pathology services – one group was conducted at each site Clients were referred to the group as they had ongoing aphasia of varying degrees however had plateaued in traditional naming therapy. They had all had inpatient rehabilitation and at least one block of traditional outpatient therapy.

Group A ran for 1 ½ hours twice a week for 4 weeks. Total of 12 hours of therapy 2 participants Go-fish game 16x2 picture cards (2 sets of these) Barriers were used Clients had to explicitly address one of the players Pointing, gesturing, writing and drawing was not permitted – these were the constraints Clients had to name the pictures (normally about 40 attempts each session) As the client improved they had to attempt to use sentences to ask for the pictures

ClientBoston Naming Test pre score (% Correct – scores out of 60) Boston Naming Test post score (% correct) EB2 (3%)8 (13%) JJ8 (13%)18 (30%)

ClientCommunication Effectiveness Index pre score Communication Effectiveness Index post score EB JJ3227 ClientModified Communication Effectiveness Index pre score Modified Communication Effectiveness Index post score EB5756 JJ55

ClientCommunication Activity Log pre score Communication Activity Log post score EB3548 JJ3430

Group ran for 1 ½ hours twice a week for 4 weeks (intensive) Total of 12 hours 3 participants Go-fish game – 16x2 picture cards (3 sets of these) used barriers clients had to explicitly address one of the players pointing, gesturing, writing and drawing was not permitted had to name the pictures (normally about attempts each session) Had to put the words into whole sentences as they improved CIAT plus – additional exercises performed each day using constraints in everyday conversation e.g. buy bread or go to travel agent. They had to rate their speech during this

ClientCommunication Effectiveness Index pre score Communication Effectiveness Index post score AM3947 GC5061 ClientModified Communication Effectiveness Index pre score Modified Communication Effectiveness Index post score AM GC AH4362.5

ClientCommunication Activity Log pre score Communication Activity Log post score AM3745 GC54

ClientBoston Naming Test pre score (% Correct) Boston Naming Test post score (% correct) AM9 (15%)13 (21.6%) GC31 (51.6%)50 (83.3%) AH6 (10%)9 (15%)

 Barthel, G., Meinzer, M., Djundja, D., Rockstroh, B. (2007). Intensive language therapy in chronic aphasia: Which aspects contribute the most? Aphasiology, 22 (4),  Breier, J.I., Juranek, J., Maher, L.M., Schmadeke, S., Men, D., Papanicolaou, A.C. (2009). Behavioural and Neurophysiologic Response to Therapy for Chronic Aphasia. Arch Phys Med Rehabilitation. 90:  Cherney LR, Patterson JP, Raymer A, Frymark T, Schooling T. (2008) Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint- Induced Language Therapy for Individuals With Stroke-Induced Aphasia. Journal of Speech, Language and Hearing Research 51 (5) :  Faroqi-Shah Y, Virion CR (2009) Constraint-induced language therapy for aggrammaticality constraints. Aphasiology. 23 (7-8);  Goral M, Kempler D (2009) Training verb production in communicative context: evidence from a person with chronic non-fluent aphasia. Aphasiology. 23 (12)  Maher LM, Kendall D, Swearengin JA, Rodriguez A, Leon SA, Pingel K, Holland A, Rothi LJ. (2006) A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12 (6):

 Meinzer M, Djundja D, Barthel G, Elbert T, Rockstroh B. (2005) Long-term stability of improved language functions in chronic aphasia after Constraint-Induced Aphasia Therapy. Stroke, 36:  Meinzer, M., Streiftau, S., Rockstroh, B. (2007). Intensive language training in the rehabilitation of chronic aphasia: Efficient training by laypersons. Journal of the International Neuropsychological Society, 13 (5),  Pulvermuller R, Neininger B, Elbert T, Mohr B, Rockstroh B, Koebbel P, Taub E. (2001) Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7):  Szaflarski JP, Ball AL, Grether S, Al-fwaress F, Griffith NM, Neils-Strunjas J, NewmeyerA, Reichhardt R. (2008) Constraint-induced aphasia therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Medical Science Monitor, 14 (5) 243 – 250.  Virion, C.R. (2008). “Go Aphasia”: Examining the efficacy of constraint induced language therapy for individuals with agrammatic aphasia. –Thesis