Aphasia

1
Aphasia Treatment effectiveness and evidence
based practice
2
Treatment Efficacy

• Efficacy improvements in an individuals
  communication as a result of clinical
  interventions provided by an SLT
• Difficult to combine results of studies due to
  differing
• Aetiologies
• Methodologies
• Types and severity of aphasia
• Nature of treatment
• Enderby and Emerson 1995

3
Systematic Reviews

• A scientific tool that can be used to appraise,
  summarise, and communicate the results and
  implications of otherwise unmanageable quantities
  of research
• Brings together separately conducted studies and
  synthesise their results
• E.g. Cochrane Database

4
Meta-analysis

• A specific statistical strategy for assembling
  the results of several studies into a single
  estimate
• Systematic reviews may or may not include
  meta-analysis, depending on whether the studies
  are similar enough so that combining their
  results is meaningful
• Strictly speaking a meta-analysis is an optional
  component of a systematic review. Not
  inter-changable words!

5
Cochrane Systematic Reviews

• Kelly, Brady and Enderby (2010)
• 30 RCTs (involving 1840 participants) comparing
• SLT vs no SLT
• SLT versus social support or stimulation
• One SLT intervention vs another intervention
• In general, trials randomised small numbers
  across a range of characteristics (age, time
  since stroke, and severity), interventions and
  outcomes

6
Kelly, Brady and Enderby (2010)

• Concluded some indication for the effectiveness
  of SLT for those with aphasia following stroke
  (as compared with Enderby 2006b).
• Intense SLT was favoured over conventional SLT
• Therapist-trained and supervised volunteers as
  effective as provision by a professional
• Insufficient evidence for effectiveness of
  specific treatment approaches

7
Systematic Reviews

• Greener, Enderby and Whurr (2006b)
• RCTs for behavioural treatments for Aphasia by
  SLTs
• 12 studies met criteria
• All had limitations in methodology, and
  incompleteness in which operational definitions
  and outcomes were communicated.
• Concluded RCTs had neither demonstrated efficacy
  nor lack of efficacy

8
Cochrane Review

• Greener, Enderby and Whurr (2010)
• Assessed the effects of drugs on language
  abilities for people with aphasia
• Particularly examined Piracetam drug which
  improves memory, cognition, attention,
  concentration, motivation
• Has reportedly shown improvements in post stroke
  aphasia in some studies
• 10 trials included
• Weak evidence that patients were more likely to
  have improved on language measures at the end of
  the trial with piracetam

9
Meta-analysis

• Greenhouse et al (1990)
• Analysed 13 pre-post tests of aphasia treatment
• Average weighted effect size of 0.8 (medium to
  large effect of change) from pre-treatment to
  post treatment
• Whurr Lorch and Nye (1992)
• 45 aphasia treatment studies
• Average effect size 0.59 between treated and
  untreated populations.
• Concluded treatments were generally effective

10
Meta-Analysis

• Robey (1998)
• Analysis of 55 articles aphasia therapy brought
  about positive clinical outcomes
• Positive outcomes were 1.83 times more likely for
  those treated in acute period than for untreated
  individuals. Advocating early intervention
• Treatment length in excess of 2 hours per week
  brought about gains exceeding those of shorter
  treatment duration
• Those with severe aphasia also made large gains
• These findings confirmed findings from earlier
  study Robey (1994)

11
Meta-Analysis

• Holland et al (1996)
• Examined improvements in individuals
  communication behaviour resulting from clinical
  interventions from SLT and exceeding what could
  be expected from spontaneous recovery alone.
• 9 group studies, all enrolling gt60 patients
• Single, left hemi stroke, receiving gt3hrs/week
  therapy for gt5m regardless of time post onset,
  made significantly more improvement than people
  with aphasia who were not treated
• 13 small group/single subject studies past period
  of spontaneous recovery. Gains made in most
  studies contributing to efficacy of chronic
  aphasia

12
Treatment of Word Retrieval Deficits in Aphasia

• Summary
• Task specific semantic therapy improves semantic
  activities
• Task specific phonological therapy improves
  phonological activities
• Limited evidence that semantic and phonological
  cueing improve naming accuracy and word retrieval
  abilities
• Salter,Teasell, Bhogal, Zettler, Foley (2009)
• Evidenced Based Review of Stroke Rehabilitation

13
Doesborg et al 2004

• RCT of 55 stroke patients 3-5m post onset
• Combined semantic and phonological deficits
• Randomly assigned to
• Semantic treatment focused on interpretation of
  written words, sentences and text (e.g. semantic
  categories, anomalous sentences, semantic
  definitions)
• Control group focused on word sound structure
  (e.g. rhyming, word length, stress patterns,
  syllabification)

14
Doesborg et al 2004

• Treatment lasted until 10-12m post onset,
  receiving 40-60 hours individual treatment
• After semantic treatment patients significantly
  improved on Semantic Association Test.
• After sound structure treatment patients
  significantly improved on phonological measures
• All patients improved on Everyday Language Test
• Improved verbal communication was achieved for
  both groups

15
Treatment for Word Finding in Aphasia Nickels
(2010)

• Therapy has item specific effects only
• Semantic and phonologically focused treatments
  are mostly successful in improving word
  retrieval.
• Semantic tasks dont have to be hard to be
  effective
• Semantic tasks are more effective with those with
  less semantic impairment
• Semantic tasks usually require the word form to
  be effective

16
Treatment of Global Aphasia

• Summary
• Patients with global aphasia experience less
  complete or slower rates of recovery
• Can still benefit from an SLT rehab programme
• Moderate evidence based on small RCT that
  intensive ecological language therapy is
  associated with improvement across modalities
• Salter,Teasell, Bhogal, Zettler, Foley (2009)
• Evidence Based Review of Stroke Rehab

17
Denes et al 1996

• RCT of 17 patients with global aphasia
• Random allocation to standard (60 sessions over
  6m) or intensive therapy (130 over 6m)
• Approach in both groups ecological
  restoration of language in conversation
• Comprehension targeted gt production
• Sessions 45-60min
• Assessed at baseline and 6m Aachen Aphasia Test

18
Denes et al 1996

• Results
• Both groups demonstrated improvement across all
  subtests.
• Between group differences significant for written
  language subtest only

19
Aphasia Treatment in Polyglots

• Miertsch, Meisel and Isel (2009)
• Does treatment of 1 language lead to improvement
  in all languages?
• 56yr old male, speaking German (L1), English (L2)
  and French (L3)
• Left CVA with a medium Wernickes aphasia severe
  WFD, semantic paraphasias, paragrammatism.
  Auditory language processing and phonological
  working memory worse than visual language
  processing
• Therapy for the study 8yrs post onset. 2x
  45min/day for 3.5weeks in French.

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Therapy

• Bilingual Aphasia Test administered
• 5 exercise types in same order every day.
• Therapy focussed on
• Oral and auditory word finding of verbs and nouns
• Exercises with prepositions
• Semantic-conceptual relationships between words
• Word finding in discourse

21
Results

• Before training best performance German.
• Post treatment, performance improved
  significantly in French as well as English.
  German did not improve.
• Further evidence that chronic aphasia can improve
• 2 Languages share a common semantic-conceptual
  memory system, though would expect improvement in
  German too. ?Length of training too short ?due to
  capabilities in that language prior to training.

22
Conclusions

• Generally accepted that SLT works!
• Basso (2005), Albert (2003), Bhogal, Teasell and
  Speechley (2003)