Kelly Knollman-Porter, Ph.D. CCC-SLP. OSLHA 2013 Columbus, Ohio

Transcription

1 Kelly Knollman-Porter, Ph.D. CCC-SLP OSLHA 2013 Columbus, Ohio

2 The presenter does not have any financial or nonfinancial relationships relevant to the content of this presentation.

3 Describe evidence based restorative treatment techniques for the management of severe, chronic aphasia. Identify current research strengths and limitations. Discuss ways researchers and clinicians can collaborate in the development and implementation of clinical research.

4 Estimate: 100,000 people will acquire aphasia each year 1,000,000 Americans are currently living with aphasia. (National Aphasia Association, 2008)

5 Inconclusive: Gender Handedness Education SES Intelligence (Plowman, Hentz, & Ellis, 2011)

6 Negative Initial aphasia severity and language outcomes 2-4 week post-stroke period was most predictive of longterm language outcomes Site and Size of Lesion (Plowman et al., 2011) Severity of Auditory Comprehension Deficits (Paolucci et al., 2005)

7 Extant research has found that treatments based on research grounded principals, while still focusing on the unique needs and desires of the individual patient are most effective. (Robey, 1998)

8 Neural circuits must be used Neural circuits should be challenged Specific skill training should be implemented Repetition of task: needed for improvement/brain reorganization Intensity Time Salience Age Transference Interference (Kleim & Jones, 2008)

9 How are you clinically implementing these strategies? What has the research shown us?

10 Criteria: Low Intensity: 1.5 hrs per week or less Moderate Intensity: 2-3 hrs per week High Intensity: At least 5 hrs per week (Robey, 1998) What is possible in the current health care environment? What is possible for our clients and their caregivers?

11 Degree of intensity varies based on the study Range Max: 23 hrs/week (Hinckley & Craig, 1998) min sessions; 6-7 sessions/week (Denes et al., 1996)

12 Methods used varied based on the study Constraint Induced Language Therapy (CILT) (Maher et al., 2006; Meinzer et al., 2004; Meinzer et al., 2005) Model-Oriented Aphasia Therapy (MOAT) (Barthel et al., 2008) Group, individual, computer, and home therapy (Hinckely & Craig, 1998; Hinckley & Carr, 2005)

13 Focus of Treatment (Skill Training) Verbal Expression (most prominent) Aphasia type and severity varied Mild to Moderate (most prominent) Most aphasia types utilized (even within studies)

14 More treatment is better. However, specific dosage recommendations based on aphasia type and severity are not quantifiable at this time. (Cherney, Patterson, Raymer, Frymark & Schooling, 2008)

15 Many variables to consider Gold Standard: Randomized Control Trials Single Subject Design Studies

16 Verbal Expression Case Study Severe non-fluent aphasia and apraxia of speech Treatment methods utilized : PACE and Intensive Language Action Therapy Conclusions: Intensive treatment can result in improved naming in individuals with severe verbal expression deficits associated with aphasia and apraxia of speech (Kurland, Silva, Burke, & Iyer, 2011)

17 Purpose: Provide a foundation for restorative treatment methods for the management of severe chronic auditory comprehension deficits. (Knollman-Porter, Dietz, & Groh, 2012)

18 Determine the: Effectiveness of an intensive treatment protocol on single word auditory comprehension in individuals with severe, chronic aphasia Clinical utility of auditory (repetition of stimuli) and visual supports (lip-reading cues) on outcomes and the ability to self-detect breakdowns.

19 Variable T.G. B.G. T.O. B.D. D.W. R.K. Months Post-CVA Age Gender Male Female Male Female Male Male Race Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Education 2-Year Master s 4-Year High School Master s Degree College Degree College High School Handedness Right Right Right Left Right Right Aphasia Type Global Wernicke s Transcortical Motor Global Global Global WAB-R AQ WAB-R Auditory Comprehension Score a Phoneme Discrimination: Immediate Phoneme Discrimination: Delayed % 85% 95% 60% 95% 65% 90% 85% 100% 55% 95% 50% Note. Months post-cva was calculated from the month in which participants were initially included in the study. Phoneme discrimination subtests (immediate and delayed) are part of the Temple University Assessment of Language and Verbal Short-Term Memory in Aphasia (Martin et al., 2007); a WAB-R Comprehension Subtest Score (300 Possible); WAB-R = Western Aphasia Battery (Kertesz, 2007). AQ = aphasia quotient (Kertesz, 2007).

20 Single subject, ABA design Stable or declining baseline achieved across three session Treatment: high intensity treatment sessions 2 hours/day; 5 days/week for 3 weeks Maintenance: gains measured one and four weeks post-treatment

21 10x7 colored images of target words Unique sets utilized between experimental phases Target: bus Semantic Foil: car Phonemic Foil: fuss

22 Target: bus Semantic Foil: car Phonemic Foil: fuss Pre-Experimental Complexity Procedure Randomly presents target word, semantic foil, or phonemic foil Stimuli presented three times non-consecutively No feedback was provided Baseline Procedure congruent with pre-experimental phase Stable or declining performance across three consecutive sessions

23 Stimuli Presented WITHOUT Visual Feedback Participant Requests Clarification. Examiner Repeats Stimuli WITHOUT Visual Cues Opportunity to Respond or Request Clarification Correct Response Incorrect Response Participant Requests Clarification. Examiner Repeats Stimuli WITH Visual Cues Opportunity to Respond or Request Clarification Correct Response Correct Answer is Provided WITH Visual and Auditory Feedback Incorrect Response Correct Answer is Provided WITH Visual and Auditory Feedback Correct Response Incorrect Response

24 Will single word auditory comprehension improve following an intensive treatment?

25 T.G. Trained Stimuli 52%; 76%; 87% Cohen s d=4.11; (large effect size) Untrained Stimuli 52%; 62%; 73% Cohen s d=2.05; (large effect size) Comprehension Error Patterns Semantic foil errors were most prevalent across all phases. B.G. Trained Stimuli 53%; 66%; 72% Cohen s d=2.79;(large effect size) Untrained Stimuli 53%; 60%; 70% Cohen s d=1.57; (large effect size) Comprehension Error Patterns Prevailing target and semantic error patterns

26 T.O. Trained Stimuli 39%; 89%; 90% Cohen s d=4.97; (large effect size) Generalization to Untrained Stimuli 39%; 60%; 43% Cohen s d=0.390; (small effect size) Comprehension Error Patterns Semantic foil errors were most prevalent B.D. Trained Stimuli 57%; 60%; 56% Cohen s d=0.181; (no treatment effect) Untrained Stimuli 57%; 75%; 70% Cohen s d=2.04; (large effect size) Comprehension Error Patterns B = semantic, T = equal semantic and target, M = target

27 D.W. Trained Stimuli 20%; 56.1%; 53.3% Cohen s d=3.72; (large effect size) Untrained Stimuli 20%; 31.1%; 20% No treatment effect was exhibited Comprehension Error Patterns Semantic foil errors were most prevalent. R.K. Trained Stimuli 40%; 58%; 67% Cohen s d=1.66; (large effect size) Untrained Stimuli 40%; 53%; 70% Cohen s d=1.05; (large effect size) Comprehension Error Patterns B = semantic, T = target word, M = target word

28 For five of the six participants, intensive treatment did improve average percentage accuracy on single word comprehension tasks following an intensive treatment protocol. Five of the six participants exhibited a generalization effect, with improved comprehension percentage accuracy on untrained stimuli.

29 Will the average number of self-initiated requests for repetition cues increase? Will the average number of self-initiated requests for lip-reading cues increase?

30 T.G. Repetition 7.5; 40; 29 Cohen s d=13.8; (large effect size) Lip-Reading Cues Not utilized during any phase of the study B.G. Repetition 23; 42; 36 Cohen s d=7.5; (large effect size) Lip-Reading Cues 0; 5.8; 5 Cohen s d=1.67; (large effect size)

31 T.O. Repetition.33; 3.2; 4.5 Cohen s d=6.7; (large effect size) Lip-Reading Cues Not utilized during any phase of the study B.D. Repetition 11.3; 41; 40 Cohen s d=1.97; (large effect size) Lip-Reading Cues 0; 10.5; 13 Cohen s d=1.18; (large effect size)

32 Repetition All participants increased the frequency of self-initiated requests for repetition across treatment and maintained increased repetition post-treatment. Lip-Reading Four of the six participants exhibited an increase in the average number of self-initiated requests for lip reading cues.

33 Will the average number of correct responses on single word comprehension tasks increase following repetition cues?

34 T.G. Correct/Incorrect Responses Following Repetition B= 4/3.5; T= 37/4.6; M= 53/3.5 Cohen s d=39; (large effect size) B.G. Correct/Incorrect Responses Following Repetition B = 18.3/4.7; T = 32/9.8; M = 30/6 Cohen s d=4.85; (large effect size)

35 T.O. Correct/Incorrect Responses Following Repetition B=.17/.17; T= 3.1/.11; M= 4/0.5 Cohen s d=3.69; (large effect size) B.D. Correct/Incorrect Responses Following Repetition B= 10/1; T= 34/6.7; M= 30/10 Cohen s d= 1.8; (large effect size)

36 All participants demonstrated an increase in single word comprehension accuracy following the use of repetition cues.

37 Will the average number of correct responses on single word comprehension tasks increase following lip-reading cues?

38 B.G. Correct/Incorrect Responses Following Lip- Reading Cues 0/0; 3.7/2.1; 2/3 Cohen s d=2.0; (large effect size) B.D. Correct/Incorrect Responses Following Lip- Reading Cues 0/0; 6/3.2; 9.5/3.5 Cohen s d=1.1; (large effect size)

39 D.W. Correct/Incorrect Responses Following Lip- Reading Cues B = 0/0; T = 1/0; M = 0/1 Cohen s d = (no treatment effect exhibited) R.K. Correct/Incorrect Responses Following Lip-Reading Cues B =.5/0; T = 1/1; M = 3/1 Cohen s d=3.87; (large effect size)

40 Of the four participants that utilized lip-reading cues, three exhibited increased comprehension accuracy.

41 Individuals with severe, chronic aphasia can improve single word comprehension of trained stimuli following intensive treatment. Treatment effects generalized to untreated stimuli for some participants. All participants demonstrated increased self-initiated requests for repetition across treatment that maintained post treatment. (Self-Awareness?) Repetition positively benefited single word comprehension for all participants enrolled in the intensive treatment protocol.

42 There is treatment potential for severe, chronic auditory comprehension deficits. Even though all were diagnosed with severe auditory comprehension deficits, each responded differently to treatment. Ultimate goal is improved quality of life for individuals with severe, chronic aphasia.

43 Management of deficits associated with severe aphasia will require: Evidence Based Restorative Approaches Evidence Based Compensatory Approaches Creativity and Flexibility TEAM Approach Patient Directed Family/Caregivers Clinicians Researchers Others???????

44 How can clinicians and researchers work together successfully in order to develop and implement evidence based treatment protocols for the management of severe aphasia? How can we bridge the gap between clinical practice and research in order to ultimately improve the quality of life of people with aphasia?

45 Kelly Knollman-Porter, Ph.D., CCC-SLP Miami University Department of Speech Pathology and Audiology Director: Miami University Aphasia Support Group

46 Barthel, G., Meinzer, M., Djundja, D. & Rockstroh, B. (2008). Intensive language therapy in chronic aphasia: Which aspects contribute most? Aphasiology, 22(4), Cherney, L. R., Patterson, J. P., 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, Denes, G., Perazzolo, C., Piani, A., & Piccione, F. (1996). Intensive versus regular speech therapy in global aphasia. A Controlled study. Aphasiology, 10, Hinckely J. J., & Carr, T. (2005). Comparing the outcomes of intensive and nonintensive context-based aphasia treatment. Aphasiology, 12, Hinckley, J. J., & Craig, H. K. (1998). Influence of rate of treatment on the naming abilities of adults with chronic aphasia. Aphasiology, 19,

47 Kleim, J. A. & Jones, T. A. (2008). Principals of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research,51, S225-S239. Knollman-Porter, K., Dietz, A., & Groh, E. (2012). Intensive auditory comprehension treatment for people with severe aphasia: Outcomes and use of self-directed strategies. (Manuscript in Preparation). Kurland, J., Silva, N., Burke, K. & Iyer, P. (2011). Treatment-induced neuroplasticity following intensive constrained and unconstrained language therapy in a case of severe non-fluent aphasia. Procedia Social and Behavioral Sciences, 23, Meinzer, M., Elbert, C., Wienbruch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 1-0. Meinzer, M., Djundja, D., Barthel, G., Elbert, T., & Rockstroh, B. (2005). Longterm stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36,

48 Maher, L., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S., Pingel, K., Holland, A., & Roth, L. (2006). A pilot study of use-dependent learning in the context of contraint induced language therapy. Journal of the International Neuropsychological Society, 12, National Aphasia Association (2008). Aphasia Frequently Asked Questions. (last accessed 1 March, 2013). Paolucci, S., Matano, A., Bragoni, M., Coiro, P., De Angelis, D., Fuxco, F.R., Morelli, D., Pratesi, L., Venturiero, V. & Bureca, I. (2005). Rehabilitation of left braindamaged ischemic stroke patients: The role of comprehension language deficits. Cerebrovascular Diseases; 20, Plowman, E., Hentz, B., & Ellis, C (2011). Post-stroke aphasia prognosis: A review of patient-related and stroke-related factors. Journal of Evaluation in Clinical Practice doi: /j x Robey, R. R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. Journal of Speech Language and Hearing Research, 41,