STAFF ARTICLE
This article was first published in 2004 in Advance for Speech Language Pathologists and Audiologists Vol. 14, Issue 40, Page 14.
CONSTRAINT INDUCED THERAPY FOR APHASIA
by Jennifer Brown, M.S., CCC-SLP
For many people living with aphasia today, the results of traditional rehabilitation are disappointing. Many are able to make at least modest progress in their communication skills during the first few weeks following onset, but when they fail to progress rapidly enough within a traditional schedule of therapy (30-60 minutes per treatment 3-5 times per week); they may no longer satisfy the requirements of their insurance companies for continued therapy to be covered. In the environment of increasingly limited reimbursement and increasing caseloads, treatment often turns to teaching patients to compensate rather than attempting to restore lost function. In addition, doctors (and sometimes speech-language pathologists) tell many patients that progress can only be made within the first year resulting in traditional therapy that often yields little functional result and leaving many people frustrated, dependent, and never reaching their full potential.
Even those who may have potential for continued meaningful improvement often are not able to receive the additional treatment they require after reaching a “plateau” following a few weeks or months of traditional treatment. A recent study showed that treatment is more effective when provided more frequently and for longer periods at a time rather than shorter treatments spread out over a longer time such as in traditional therapy schedules.[i]
Constraint Induced (CI) therapy has been used by physical and occupational therapists to help patients regain the ability to use an arm or leg that has been affected by stroke. Developed by Edward Taub, Ph.D., from the University of Alabama, these principles aim to overcome the “learned non-use” that results from stroke survivors’ experience of failure during initial attempts to use the affected extremity. Eventually, the new pattern of using only the unaffected (or less affected) side becomes so strong that there are no longer even any attempts to use the affected side.[ii] To overcome this learned non-use, therapists constrain the use of the “good” side and tasks must be completed using the affected extremity. Treatments are intense and frequent lasting 6 hours a day 5 days a week in most cases.
Just as a person would naturally use his or her stronger hand to complete daily tasks, many people with aphasia find easier ways to communicate when speech is too difficult or time consuming. Patients experience failure during early attempts to communicate and eventually the learned non-use results in fewer verbal attempts and greater instances of compensation. Increased understanding on the part of their conversation partner rewards these compensations and, therefore, patients increasingly forgo verbal communication in favor of more successful communication methods. By doing so, they not only begin removing themselves from the people and activities they once enjoyed, they also allow the damaged part(s) of the brain to remain unused. Constraint Induced Aphasia Therapy (CIAT) aims to reorganize those parts of the brain that control language but have been damaged by stroke.[iii],[iv],[v] In a way, it’s speech treatment with “half your brain tied behind your back”—the good half.
A German study[vi] concluded that CI therapy for aphasia was effective; however, few, if any, programs have used these principles to treat expressive aphasia. In an attempt to study the effects of CIAT in an English speaking population, we adapted CI principles for use in speech-language treatment sessions with two volunteer participants. When modified to treat aphasia, CIAT limits the patient’s use of writing, gesturing, drawing, or even giving up on the message altogether during the therapy session and, therefore, forces the brain to adapt and find an alternate way to express the idea—verbalization and spoken words. Patients in the program receive treatment 3 ½ hours a day 5 days a week for at least 2 weeks. Homework assignments each night and on weekends continue the language stimulation. It is thought that the constraining of compensatory strategies combined with extensive and frequent treatments has the greatest effect on how much progress a patient achieves.
Without the typical 30 to 60 minute time limit, treatment can focus on restoring functions of the brain rather than using a more compensatory approach that is often necessary with the limited frequency and duration of treatment with traditional schedules. Treatment so far has been effective both one-on-one and in groups. We have provided CIAT in groups of up to three participants to one therapist with most reporting a preference for the group treatments. They cite the increased feedback, examples of how others are progressing with their language, and a feeling of support in the group setting.
Participants made significant progress during their courses of treatment. Participant 1 was 1-year post onset with treatment mainly addressing word finding. After 4 weeks of treatment, his progress (figure 1) in areas related to word finding skills allowed him to return to operating his business, record a radio commercial, and participate in a television news interview.
Figure 1
Participant 2 was 5 years post-onset with treatment focused on increasing fluency, prosody, and grammatical completeness. Her progress (figure 2) occurred over the course of 2 weeks of treatment.
Figure 2
Even after treatment ended in the clinic, these patients were able to continue their progress by continuing with practice activities at home and with family and friends. The learned non-use gives way to increased communicative confidence and willingness to communicate in increasingly demanding contexts.
Unfortunately, CIAT is not currently covered by insurance. In terms of the total number of treatment hours, two weeks of CIAT is equal to roughly 3 months of more traditional treatment (1 hour 3 times a week). By demonstrating that patients can make more progress given the same number of treatment hours it is hoped that third party payers will find that this approach to aphasia treatment not only produces better results in many cases, but is cost effective as well with regard to issues such as total cost of treatment, need to return for additional treatment at a later time, and patients’ ability to communicate with caregivers for timely management of other medical conditions.
Current treatment options for expressive aphasia are too few and the goals we set for many of our patients are far too low. Given the results of CIAT with these first two participants, research into this therapeutic approach to expressive aphasia would be worthwhile.
Additional Reading
Musso, M., Weiller, C., Kiebel, S., Muller, S., Lulau, P., and Rijntjes, M.. (1999). Training-induced plasticity in aphasia. Brain. 122, 1781-1790.
Small, S.L. (2000). The future of aphasia treatment. Brain and Language. 71, 227-232.
[i] Bhogal, S.K., Teasell, R., and Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke. 34, 987.
[ii] Taub, E., Uswatte, G., and Pidikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation: A clinical review. Journal of Rehabilitation Research and Development. 36, 237-251.
[iii] Leipert, J., Bauder, H., Miltner, W.H.R., Taub, E., and Weiller, C. (2000). Treatment-induced cortical reorganization after stroke in humans. Stroke. 31, 1210-1216.
[iv] Liepert, J., Miltner, W.H.R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., and Weiller, C. (1998). Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neuroscience Letters. 250, 5-8.
[v] Levy, C.E., Nichols, D.S., Schmalbrock, P.M., Keller, P., and Charkeres, D.W. (2001). Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. American Journal of Physical Medicine and Rehabilitation. 80, 4-12.
[vi] Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., and Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke. 32, 1621.