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Constraint-Induced Language Therapy

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Kristin Knight

on 10 December 2013

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Transcript of Constraint-Induced Language Therapy

Constraint-Induced Language Therapy

Summary of CILT
CILT Method
Massed practice of language
(3-4 hours per day) for 10 days
PICO Question
P:

Do adults with chronic moderate-severe aphasia

I:

using Constraint-Induced Language Therapy (CILT)

C:

as compared to traditional therapy approaches or
approaches which allow the use of non-verbal communication

O:

increase their communicative effectiveness after intervention with CILT?
Maher et al., 2006
Nine participants with chronic moderate aphasia
Compared PACE to CILT
Groups not randomly assigned, but comparable
Assessors blinded for narrative portion only
Treatment fidelity was reported
Pre-, post- and one-month follow-up testing data obtained with WAB, BNT and ANT
Kurland et al., 2012
Two participants with chronic moderate-severe aphasia
Single-subject, multiple-baseline approach across behaviors
Confrontation naming probes collected during 5 phases - 1) 2 week baseline, 2) PACE, 3) CILT, 4) post-treatment, and 5) maintenance
Participants treated simultaneously, first with PACE, then with CILT
Pre- post-treatment testing included overt naming fMRI, BDAE-3 and BNT-2
Pulvermuller et al., 2001
Cherney et al. 2008
Evidence-based systematic review summarizing evidence for intensity of treatment and CILT
CILT examined in 5 studies of chronic aphasia
Addressed influence of CILT on measures of language impairment and communication/activity participation; looked at which treatment outcomes are maintained following CILT
60% of participants had nonfluent form of aphasia, typically described as Broca's aphasia
Theoretical Origins
Based on principles of CIMT
Unaffected limb restrained to facilitate use of affected limb (i.e. hemiparetic arm)
Positive results from CIMT prompted researchers to determine if similar benefits can be reached in other domains using CI therapy
Neural Plasticity & CILT
10 Principles of Plasticity
(Kleim & Jones, 2008)
Principle #4 - Repetition
Principle #5 - Intensity

Induction of plasticity requires sufficient repetition and sufficient training intensity
3 Main Principles of CILT
Massed practice (repetition & intensity)
Constraint of the communication mode used (speech only)
Forced use of spoken language in communication activities
Same amount of therapy over same duration = intensity was controlled in this study.
Amount of therapy, levels of difficulty and communication burdens were the same in both groups.
Main difference was that there were no communicative constraints in the PACE group - gestures, writing, pointing were accepted.
CILT participants were encouraged to reduce error as much as possible.
PACE Results
5 participants in PACE group
Significant change noted on WAB & BNT & ANT for 1 out of 5 participants
The participant who improved had chosen to communicate exclusively via speaking
Post-tx narrative discourse preferred for only 2 participants
No evidence of continued gains during follow-up interval
Higher incidence of severe apraxia
CILT Results
4 participants in CILT group
Significant change noted on WAB & BNT for 3 out of 4 participants; 2 out of 4 participants on ANT
WAB gains further increased at 1-month follow-up
Post-tx narrative discourse preferred for three participants
Participant with severe apraxia showed improvements
PACE Results
Participants allowed to request cards using any speech modality
Clinicians attempted to elicit enough info to correctly identify a target
Stronger mean performance during PACE than during baseline
Seven-month post assessment for one participant found large drop in performance; better than baseline, not as high as CILT
CILT Results
Moderate-severe apraxia of speech did not deter response to treatment following intensive language-action tx like CILT
Faster gains and stronger mean performance for CILT than PACE
Seven-month post-assessment for one participant found large drop in performance, but performance still 25% better than baseline
fMRI results
fMRI comparisons assessed
After PACE vs baseline
After CILT vs after PACE
After CILT vs baseline
Naming performance assessed while in scanner
Only overall tx effect comparing CILT vs baselines demonstrated a strongly L lateralized pattern of activation
Significant activation for 1 participant in L perilesional clusters along lesion site in Broca's area
Participants: 2-3 patients + 1-2 therapists
Activity: structured card game using 32 cards (16 pairs)
Communication: spoken words or sentences (no gestures/pointing)
Task: player 1 picks one card and explicitly addresses another co-player to request a card with the object shown; co-player determines if he/she has the card and either gives player 1 the card or explicitly denies the request.
Shaping: cards become more complex across training sessions requiring players to use more advanced verbal communication to request cards
Reinforcement: given when patients use a request/response that corresponds to their response level
Performance levels can vary within a group
Patients are encouraged to activate his/her upper level of language skills
x


Pros
CILT had positive effects for overall aphasia battery scores and subtests of auditory comprehension, word retrieval, repetition and lexical decision
CILT had positive outcomes for several measures of communication activity/participation in 3 out of 5 studies
Meinzer et al. (2005) & Maher et al. (2006) reported some maintenance outcomes at 6 months & 1 month respectively
Cons
Small number of studies addressing treatment intensity vs larger number of studies examining language treatment
No data which addressed the effect of CILT in patients with acute aphasia
Differences in outcome measures made it difficult to compare results
Quality indicators across studies was lacking
The Nutshell
Five studies involving 90 participants reported that CILT resulted in positive changes on measures of language impairment &communication activity/participation
Majority of patients in studies were nonfluent & moderately impaired - generalization limited to individuals with other aphasic characteristics
Differences in outcome measures used
More measures at communication activity/participation level + quality of live measures needed
Need more studies with quality indicators related to random assignment of subjects, assessor blinding and evidence of treatment fidelity
Need to separate impact of constraint vs intensity
Based on Jim Harvey's speech structures
17 patients with chronic moderate aphasia
Randomly assigned to CILT group or conventional tx group
No differences between groups
Pre- post-test measures obtained using Aachen Aphasia Battery (AAB) and CAL
Same amount of therapy (30 hours)
Spread over different duration
CILT: over 10 days
Conventional: over 3-5 weeks
Patients receiving CILT were not informed they were receiving special treatment
Raters for both measures were blinded
Results:
Patients who received CILT showed substantial improvement on 3/4 AAB sub-tests and reported a significant increase of 30% in the amount of communication in everyday life after treatment
Patients who received conventional treatment improved on 1/4 AAB sub-tests and no improvement on CAL
1A level of evidence
2b level of evidence
2c level of evidence
References
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(5), 1282-1299.

Huber W, Poeck K, Weniger D, Willmes K. Aachener Aphasie Test (AAT).Handanweisung Göttingen, Germany: Beltz Verlag; 1983.

Kaplan, E., Goodglass, H., & Weintraub, S. (2000). The Boston Naming Test. Philadelphia: Lee & Febiger.

Kertesz, A. (1982). Western Aphasia Battery. San Antonio: The Psychological Corp.

Kurland, J., Pulvermuller, F., Silva, N., Burke, K., & Andrianopoulos, M. (2012). Constrained Versus Unconstrained Intensive Language Therapy in Two Individuals With Chronic, Moderate-to-Severe Aphasia and Apraxia of Speech: Behavioral and fMRI Outcomes. American Journal of Speech-Language Pathology, 21(2), S65-S87.

Maher, L. M., Kendall, D., Swearengin, J. A., Rodriguez, A., Leon, S. A., Pingel, K., et al. (2006). A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12(6), 843-852.

Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., et al. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32(7), 1621-1626..
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