Janet Patterson PhD CCCSLP VA Northern California Healthcare System Martinez CA and California State University East Bay Hayward CA Objectives Define Evidencebased Practice and identify a system for evaluating the strength of the evidence ID: 909141
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Aphasia Treatment:Evidence-based Practice and The State of the Evidence
Janet Patterson, Ph.D., CCC-SLPVA Northern California Healthcare SystemMartinez CAandCalifornia State University East Bay Hayward CA
Slide2Objectives
Define Evidence-based Practice and identify a system for evaluating the strength of the evidenceIdentify evidence for impairment-based treatment techniques Identify evidence for activity/participation-based treatment techniques Identify evidence for emerging treatment techniques
Slide3Evidence-based Practice
Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. (Sackett et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1)
http://www.asha.org/members/ebp/intro.htm
A fourth component is the environment or facility in which treatment takes place.
Slide4Finding the evidenceASHA National Center for Evidence-Based Practice (N-CEP)
http://www.asha.org/Members/ebp/default/ASHA Division 2http://www.asha.org/members/divs/div_2.htmANCDSwww.ancds.org
PsycBITE Psychological Database for Brain Impairment Treatment Efficacy
http://www.psycbite.com
Agency for Healthcare Research and Quality
http://www.guideline.gov/
The Cochrane Collaboration
http://www.cochrane.org/
Centre for Evidence-Based Medicine
http://www.cebm.net/
Slide5SORTing the EvidenceBy Outcome Measures
Patient-oriented evidence measures outcomes that matter to patientsDisease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomesEbell, Siwek, Weiss, Woolf, Susman, Ewigman & Bowman, 2004
Slide6Grading the Evidence
The grade of a recommendation for clinical practice is based on a body of evidence (typically more than one study). This approach takes into account 1) the level of evidence of individual studies; 2) the type of outcomes measured by these studies (patient-oriented or disease-oriented); 3) the number, consistency, and coherence of the
evidence as a whole; and 4) the
relationship
between benefits, harms, and
costs.
Ebell, et al., 2003
Slide7Strength of recommendation
A = Consistent, good-quality patient-oriented evidenceB = Inconsistent or limited-quality patient-oriented evidenceC = Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening
Ebell, et al., 2003
Slide8ASHA & Evidence
National Center for Evidence-based PracticeCompendium of evidenceSystematic ReviewsEvidence MapsAdvisory Committee on Evidence-based PracticeGuides the work of N-CEPIdentify clinical questions
Slide9ASHA Homepage > Research Tab > Evidence-based Practice
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Slide11Slide12
Slide13
Slide14
Slide15
Slide16ANCDS & EvidenceWriting Groups
Practice Guidelines
Slide17
Slide18
Slide19CautionsStudy quality Strength of evidence Practice Guidelines
Methodology is often inconsistentThe lack of evidence = poor evidenceConsider all EBP components in treatment decisions
Slide20A Word about Effect sizeMany methods of calculationMost common method references means and variability of two groups
d = (M post-treatment – M pre-treatment) SD Pre-treatmentBetween or within subjects.2 = small .5 = medium .8 = large (Cohen, 1962)Single subject designs (Beeson & Robey, 2008)
Slide21Aphasia Treatment
Slide22Aphasia language treatment
Treatment is beneficialKelly, Brady & Enderby (2010) http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000425/frame.htmlRobey (1998, 1994)Salter, Teasell, Bhogal, Zettler, Foley (2010)http://www.ebrsr.com/reviews_list.php
Insufficient evidence to state which treatment for which patient in which dosage
Slide23Impairment-based treatment techniques
Slide24Impairment-based treatment techniques
Lexical retrievalConstraint-Induced Language TreatmentCueing HierarchySemantic Feature TherapyReadingWritingComplexity Account of Treatment Effectiveness
Slide25Lexical Retrieval
Slide26Theoretical FoundationSemantic network or feature networkA way of thinking about knowledge in which there are
concepts and relationships among them.A diagrammatic representation comprising some combination of boxes, arrows and labels.Storage, central processing or retrieval deficit Collins & Loftus, 1975
Slide27Example of a semantic network
Slide28A concept (bird) defined as set of features
defining features - necessary to the meaning of the item (robin has a red breast) characteristic features - descriptive but not essential How close is target to exemplar Target = chicken, sparrow, robin, penguinExemplar = robin
Smith, Shoben & Rips, 1974
Slide29Example of semantic feature set
Slide30Cognitive neuropsychological processing model of word retrieval
Kay, Lesser & Coltheart, 1992
Slide31Treatment examplesStimulation-facilitation (Schuell, 1964)
CuesCueing hierarchy (Linebaugh & Lehner, 1977; Patterson, 2001)Semantic or Phonologic (Raymer et al., 1993; Wambaugh et al., 2002)Personal cues (Marshall, Karow, Freed & Babcock, 2002)Semantic Features (Boyle & Coelho, 1995)Gesture (Raymer, Singletary, Rodriguez , Ciampitti, Heilman & Rothi , 2006; Rose, Douglas & Matyas, 2002)
Slide32Evidence, ES & ConclusionsEvidence
Some RCTs but not large scale clinical trialsNo Systematic Reviews One meta analyses (Wisenburn & Mahoney, 2009)Many single subject designs or case studiesEffect SizesRobey & Beeson (2005) reported tentative ES of 4.0, 7.0 and 10.1 calculated from 12 studiesPoint is that Cohen’s d is meant for group studies and much of our work is single subject studies, requiring a different comparisonCompare an individual study to these benchmarks
Slide33Task Specific v GeneralIndividual v GroupSLP v Volunteer
Conventional v Functional
Treatment v Social Support
Treatment v No Treatment
Kelly, Brady & Enderby, 2010
Slide34Consistent results across sources of evidence
RCT, EBSR, individual reviewModerate to strong evidence in favor of treatmentTask specific and item specific effectsPhonological v semantic cueingNoun v verb trainingWeak evidence in favor of generalization to untreated items and maintenanceInsufficient evidence to state which treatment for which patient in which dosage
Slide35Constraint Induced Language Therapy
Slide36Theoretical Foundation
Pulvermller et al. (2001) reasoned that principles of CIMT could be applied to aphasia treatmentLearned non use observed in persons with aphasiaFailed communicative attempts “punished” (i.e. frustration or embarrassment) leading to even fewer attemptsCompensatory communication attempts rewarded and thus prevailFewer and more difficult communicative attempts occurredDoes “use it to improve it” apply to language change in persons with aphasia?
Slide37Principles of CILT
Forced verbal language use and application of constraintVerbalization requiredCompensatory strategies prohibited (constrained)Intensive treatment scheduleMassed practice3 hrs/day 5 days/week 2 weeksShaping verbal responses Begin with words or short phrasesMove to longer and more complex utterances
Slide38Model
Slide39Use dependent Cortical Reorganization
Neuronal plasticityEvents that regulate the capacity of the CNS to change in response to injury or physiological demandsPotential for changeSeveral mechanisms of change (i.e. synaptogenesis, dendritic arborization)
Slide40CIMT example (Mark & Taub, 2004)
Slide41CILT & Intensity Questions
10 questions (PICO format)Influence of CILT (5)Influence of Treatment Intensity (5)Two factorsAphasia: Acute vs. chronicOutcome measure: Impairment vs. Activity/ParticipationMaintenance Question (Intensity & CILT)
Slide42Studies included in two reviews
Cherney, Patterson, Raymer, Frymark, Schooling (2008, 2010)CILTBerthier et al., 2009Breier et al., 2006, 2007, 2009Faroqi-Shah et al., 2009
Goral & Kempler, 2009
Kirness
& Maher, 2010
Maher et al., 2006
Meinzer
et al., 2004, 2005, 2006, 2007a, 2007b, 2008, 2009
Pulvermuller et al., 2001,
2005
Richter et al., 2008
Szaflarski
et al., 2008
Slide43Intensity
Bakheit, et al., 2007Basso & Caporali, 2001Denes et al., 1996Harnish et al., 2008Hinckley & Carr, 2005
Hinckley & Craig, 1993
Puvermuller et al., 2001
Ramsberger & Marie, 2007
Raymer et al., 2006
Slide44CILT
19 studies with 202 participantsLanguage impairment measures: CILT resulted in positive changes Communication activity/participation measures: CILT resulted in positive language outcome measure changes; one large effect size
Data available mostly for people with
chronic aphasia
. One study showed positive effect for 3 individuals with
acute aphasia.
Maintenance of CILT effects:
reported to lead to positive changes; again no effect sizes calculable
Evolution of studies:
Relatives; Reduce time; pharmacotherapy; RH activation; syntax module; multiple activities
Slide45Treatment Intensity
9 studies with 170 participantsLanguage impairment measures: Increased treatment intensity was associated with positive changes in both chronic and acute aphasia. –BUT-Bakheit et al., with 97 participants (more than ½) showed no effect of intensity
Activity/Participation measures: Bakheit
et al., results notwithstanding, equivocal results, favoring neither more intensive nor less intensive treatment for persons with chronic aphasia.
Observations suggest that there can be
complex interactions
among intensity of treatment schedule, type of treatment, and type of outcome measure.
Maintenance of treatment:
little data; also equivocal, favoring more intense treatment for one outcome measure and less intense for the other.
Slide46Effect Sizes favoring Constraint Induced Language Treatment for Impairment and Activity/Participation outcome measuresActivity Participation
Impairment
Slide47Activity/participation Based treatment techniques
Slide48Slide49Blackstone & Hunt Berg, 2006
Slide50Life Participation Approach to AphasiaCore Components
The explicit goal is enhancement of life participation. All those affected by aphasia are entitled to service. Both personal and environmental factors are targets of assessment and intervention.Success is measured via documented life enhancement changes. Emphasis is placed on availability of services as needed at all stages of life with aphasia.
Chapey, Duchan, Elman, Garcia, Kagan, Lyon & Simmons Mackie (1999)
Slide51Outcome Measures
Test resultsConnected speechCIUs (Brookshire & Nicholas, 1993)Content units (Yorkston & Beukelman, 1980)Perceptual dataInterview with PWA, family, friends or associates (Lomas et al., 1989)Activity reports and surveysADLs, social occasions, conversation, job successQuality of life (Hilary, Byng, Lamping & Smith, 2004)
Slide52Activity/Participation-based treatment techniques
Group treatmentConversation participationTreatment for caregivers or conversation partnersPersonal narratives; scriptsAAC
Slide53Group treatment
Slide54Types of Group TreatmentGoal-directed
Conversation participation (Simmons-Mackie, 2000; Vickers, 1998)Specific linguistic goalCooperative learning (Avent, 1997)Reading and writing (Cherney, Merbitz & Grip, 1986; Clausen & Beeson, 2003)Life activities (i.e. book group (Bernstein Ellis & Elman, 2006))Support (www.naa.org) Information (Avent, Glista, Wallace, Jackson, Nishioka &Yip, 2004)
Slide55Effect Sizes for Group vs. Individual Treatment --- RCTs ---
Kelly, Brady, Enderby, 2010Evidence, ES and Conclusions
Slide56Change Score
Salter, Teasell, Bhogal, Zettler & Foley (2010)Change Scores and Total Number of Participants for Studies of Group Treatment
Slide57RCTs
Inconsistent data supporting effectiveness of group treatment over individual treatmentLimited support for social groups and language changeOther published studiesModerate support for group treatment and language changeVarying methodology and outcome measures
Slide58Anecdotal and qualitative information
Improved quality of life (Avent & Austerman, 2003)Feeling of community (Bernstein-Ellis & Elman, 1999)Improved sense of self (Elman, 2007)Safe environment in which to practice communicatingPeople “vote with their feet”Number of aphasia groups increasing
Expanded variety of group typesBook group, artistic expression, theater group, exercise group, choral group
Slide59Conversation participation
Slide60Script TrainingClient and clinician create short, relevant scriptsRepetition until mastery
Personal cues (Freed, Marshall, Nippold, 1995)Computer directed (Cherney, Halper, Holland & Cole, 2008)Speech-language pathologist as trainer (Youmans, Holland, Muňoz &Bourgeois, 2005)Insertion into connected speech situation
Slide61Supported Conversation and Partner TrainingCommunicative competence of a PWA can be uncovered by a skilled partner
Typically family members or close friendsConsider layers of trainingPartner changes behavior so PWA will change
Armstrong & Mortenson
Slide62More Conversation Treatment Techniques
PACE Promoting Aphasics’ Communicative Effectiveness (Davis & Wilcox, 1985)Collaborative exchange of informationRET Response Elaboration Training (Kearns, 1985)Expand utterance contentConversational Coach (Hopper, Holland & Rewega, 2002)
Clinician coaches PWA and partner
Reciprocal Scaffolding
(Avent &
Austerman
, 2003; Avent, Patterson, Lu & Small, 2009)
Apprenticeship model with communication embedded within meaningful contexts
Slide63Evidence, ES, ConclusionsScript training
Approximately 15 studies PWA have variable characteristicsMild to moderate aphasiaTypically 6 months or more post onsetsOutcomesImproved production of practiced scriptsSome generalization to other communication situationsSlightly increased speaking rateError reductionInsufficient evidence for systematic review - yet
Slide64Partner training
Facilitate desirable behavior or inhibit undesirable behavior by partnerEvidenceEffective for improving communication of partnerProbably effective for persons with chronic aphasiaInsufficient evidence for persons with acute aphasia or changing language impairment, psychosocial adjustment or quality of life
Simmons-Mackie et al., 2010; Turner & Whitworth, 2006 http://www.asha.org/members/reviews.aspx?id=7499
Slide65Anecdotal outcome reports
Improved interactionMore successful conversation turnsFewer interruptionsFewer turns devoted to repairSuccessful social validationMore accurate sense of partner’s aphasiaMaintenance and generalization of behavior
Turner & Whitworth, 2006
Slide66More Conversation Treatment techniquesPACE and RET
Several studies investigating each treatmentPrimarily positive results reportedTrained itemsUntrained itemsGeneralization itemsNo systematic review of the techniquesSingle subject design studies
Slide67Conversational Coaching and Reciprocal Scaffolding Few studies investigating each treatment
Primarily positive results reportedSome generalization reportedNo systematic review of the techniqueSingle subject design studies
Slide68Treatment Influences
Slide69Intensity and DosageTheories supporting treatment intensityHebbian cell assemblies
(Hebb, 1949)Education learning theory http://www.emtech.net/learning_theories.htmNeuronal plasticity (Kleim & Jones, 2008)Dosage (frequency, intensity, duration) Early aphasia treatment research (Darley, 1972)
Slide70Impairment
Activity/Participation
ES for Outcome Measures for studies investigating intensity of treatment
Cherney, Patterson, Raymer, Frymark
& Schooling, 2008;
Frymark, Cherney, Patterson & Raymer, 2010
Slide71Errorless (Reduced Error) LearningTheoretical foundation
Initially demonstrated in animal learningMemory rehabilitation Error behavior can be self-reinforcing > eliminateContrastErrorless learningError eliminationError reductionErrorful learning (cueing hierarchy)Errors not controlled
Slide72Review of 27 studies
91 outcome measures at three timesImmediate benefit = 78% yes; 25% noFollow up benefit = 38% yes; 27% noGeneralization = 30% yes; 67% no
Variations
Aphasia type and fluency
Therapy type (expressive, receptive, mixed,
nonlangugae
)
Technique (Errorful, error reducing, error elimination)
Fillingham, Hodgson, Sage & Lambon Ralph (2003)
Slide73Neuronal Plasticity
Principles of experience-dependent neural plasticityUse it or lose itUse it and improve itSpecificityRepetition mattersIntensity matters
Time matters
Salience matters
Age matters
Transference
Interference
Kleim & Jones, 2008; Raymer et al., 2008; Raymer, Maher, Patterson & Cherney, 2007
Slide74Experience-dependent neuronal plasticity is the basis for learning and influences recovery
In the presence of treatmentWithout treatment as one navigates the worldResearch aimed at translation of neuroscience to neurorehabilitationNeuroimaging studiesDosageApplication of principles individually and in combination
Slide75Emerging Treatments
Slide76Emerging treatment techniquesPharmacotherapyComputer-aided treatment
Repetitive Transcranial Magnetic Stimulation (rTMS)Transcranial Direct Current Stimulation (tDCS)Epidural cortical stimulation
Slide77Pharmacotherapy Drugs investigated in RCTs
Piracetam Weak evidence in support but concern for side effectsDextran – insufficient evidenceBifemelane - insufficient evidenceBromocriptine - insufficient evidenceIdebenone - insufficient evidencePiribedil - insufficient evidence Greener, Enderby & Whurr, 2010
Slide78Additional studies of drug therapy in aphasia
Piracetam – strong, positive evidence in favor (n=5)Bromocriptine – strong evidence against (n=4)Levodopa – moderate evidence in favor (n=1)Amphetamines – moderate evidence in favor (n=2)Bifemelane
– insufficient evidence (n=1)Dextran – moderate evidence against
(n=1)
Moclobemide
– insufficient evidence
(n=1)
Donepizil – moderate evidence in favor during active treatment
(n=2)
Memantine
– moderate evidence in favor with CILT
(n=1)
Salter, Teasell, Bhogal, Zettler & Foley, 2010
Slide79Computer-based Treatment
Not so new but re-emerging techniqueAs primary treatment (Doesborgh, van de Sandt-Koenderman, Dippel, van Ahrskamp, Koustall & Visch-Brink, 2004; Cherney, Halper, Holland & Cole, 2008)Practice of skills learned in treatmentTelehealthStrong evidence in favor of improvement at impairment levelLimited evidence for generalization functional communication
Salter, Teasell, Bhogal, Zettler & Foley, 2010
Slide80Cortical stimulationRepetitive Transcranial Magnetic Stimulation
(rTMS)How it worksNoninvasive; Cause depolarization of neurons Place electrodes on scalp at regions of interest R perisylvian area or RH Broca’s area homologueInduces weak electric current in rapidly changing magnetic fieldFacilitates neuronal activity Some evidence in favor Patients with chronic nonfluent aphasiaImprovement in namingSome improvement in spontaneous speech
Salter, Teasell, Bhogal, Zettler & Foley, 2010; Martin, Naeser, Ho, Doron, Kurland, Kaplan, Wang, Nicholas, Baker, Alonso, Fregni & Pascual-Leone, 2009
Slide81Transcranial Direct Current Stimulation (tDCS)
How it worksApplication of weak electrical currents (1-2 mA) to modulate the activity of neurons Polarity determines whether excitability is increased or decreasedLimited evidence in favorPatients with chronic nonfluent aphasiaImprovement in naming Salter, Teasell, Bhogal, Zettler & Foley, 2010;
Baker, Rorden & Fridriksson, 2010
Slide82Epidural Cortical Stimulation
How it worksImpulse generator implanted subclavicularlyEpidural electrode embedded over dura of target cortical areaNeurons stimulated; perhaps to rewire themselvesLimited evidence in favor when used with behavioral treatmentChronic nonfluent aphasia
Cherney, 2009; Cherney & Small, 2007
Slide83Summary
Evidence-based medicine is the integration of best research evidence with clinical expertise and patient valuesN-CEP, PsychBITE, ANCDS, Division 2 are sources of evidenceAphasia therapy is effective; dosage is unclear.Moderate evidence for effectiveness of lexical retrieval treatment; weak evidence for generalization of treatment gains.Moderate evidence for effectiveness of CILT in chronic nonfluent aphasia.
Moderate
(small studies) or inconsistent (RCTs) support for group treatment.
Modest support for script training (multiple forms).
Slide84Modest support for communication partner training.
Modest support for PACE and RETGreater intensity may be more effective than lesser intensity
Errorless, reduced error and errorful treatment techniques are effective
Principles of neuronal plasticity positively influence treatment effectiveness
Inconsistent evidence supporting pharmacological treatment.
Computer-based treatment effective at impairment level; inconsistent evidence for generalization.
Some indication that cortical stimulation in conjunction with behavioral treatment may improve naming.