Constraint-Induced Therapies in the Treatment of Aphasia

2/5/2016
I have no relevant financial or
non-financial relationships to
disclose.
Owensboro Health Regional Hospital
GOALS
Discuss history of CIAT
Identify major elements of
CIAT
Introduce steps used in
CIAT
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THE HISTORY OF CIAT
Introduce CIAT Plus
Review the system of
supports
CIAT was developed as
an outgrowth from PT
work of constraining the
good limb and forcing
use of the impaired limb
Constraint Induced
Therapy (CIT)
The theory that by
limiting use of
unaffected limb you
promote use of affected
limb
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30 seconds
ORINGINALLY CREATED
TO TREAT CHRONIC
APHASIA
6 MONTHS OR LONGER
Years
of
research
BENEFITS THOSE WITH
LONGER POST STROKE
EPISODES AND THOSE
WHO HAVE BEEN
DISMISSED FROM
TREATMENT
UNRESOLVED
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BUT ALSO BENFICIAL
FOR RECENT APHASICS
CIAT doesn’t constrict a
body part…..
SO WHAT IS CIAT?
But we do attempt to
constrict
certain behaviors…….
Specifically,
Therapy that avoids
using
strategies such as
gesturing, drawing,
writing
OR USING OTHERS
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Avoiding all means of
communication expect
speech
CIAT TRAINS THE
PATIENT TO AVOID THE
USE OF
COMPENSATORY
TECHNIQUES TO
COMMUNICATE
Pulvermuller (2001)
strongly argued that
patients with aphasia
use the accessible
communication system
that requires the least
amount of effort.
The use of strategies
other than speech is
considered to lead to
non use and avoidance
of verbal communication
Speech use is stagnant
Non speech behavior
become habitual.
Other symbols system
not consistently used
so what happens?
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Increases speech
avoidance and
dependence on others
OUR GOAL FOR OUR
PATIENTS IS
COMMUNICATION
SUCCESS
BUT WE MAY FOSTER
NONUSE BY TRAINING
COMPENSATORY
TECHNIQUES
IS OUR THERAPY
PROMOTING LESS
EFFECTIVE, BUT MORE
EASILY ACCESSIBLE
COMMUNICAITON
SYSTEMS?
DO THESE
COMPENSATORY
COMMUNIATION
STRATEGIES AIDE IN
LANGUAGE RECOVERY?
OR
DO THEY
STRENGTHEN
LEARNED NON USE
OF SPEECH?
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Characteristics of CIAT
1. CONSTRAINTS
•
•
•
•
WAIT, WAIT, WAIT…..
IGNORE GESTURES
DISREGARD HEAD MOVEMENTS
GUIDING TO USE SPEECH THAT
THEY CAN STILL ACCESS
KEEP OTHERS QUIET
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PATIENT MUST TALK !!!!!
Now that’s a barrier
2. USE OF BARRIERS
FACILITATES, ALMOST
REQUIRES SPEECH
HIDES BODY PARTS,
POINTING
PREVENTING LEARNED
NON USE FROM
INTERFERING
3. MASSED PRACTICE
8 hours and 48 minutes
of therapy a week were
necessary to produce a
significant treatment
effect
Bhogal, et al (2003)
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No way, not with my caseload
Many recent studies
strongly suggest longer
tx sessions are
beneficial for neural
rewiring
45 minutes in the morning
5 days = 1 hour 46 minutes
6 days = 1 hour 28 minutes
7 days = 1 hour 16 minutes
30 minutes in the early
afternoon
15-30 minutes late
afternoon
Breaks are built in….
ENLIST OTHERS
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4.
ALWAYS HIGH NUMBER OF
TRIALS
I’M SORRY WHAT DID YOU
SAY?
SAY IT AGAIN
HUH?
5. SHAPING OF SPEECH
THE GOAL IS SPEECH
APPROXIMATIONS
ACCEPTED
MOVE TOWARD
IMPROVED SPEECH
6. BEHAVIORALLY AND
PRAGMATICALLY RELEVANT
ACTIVE ENGAGEMENT
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ONE ON ONE
VERSUS
GROUP ACTIVITY
7. SYNTAX
CONSTRAINTS
REQUEST
RESPONSE
REPLY
DONNA DO YOU HAVE…..
“YES, I HAVE 4 RED
SQUARES”
OR
“NO, I DO NOT HAVE 4
READ SQUARES”
ALWAYS USING THE
SAME SYNTAX
CONSTRAINTS,
SAME ORDER,
COMPLETE SENTENCES
8. GRADATIONS
OF
LANGUAGE
INTRODUCE MORE
COMPLEX UTTERANCES
AS SESSIONS
PROGRESS
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9. WRITTEN SUPPORTS
VARIOUS KEY WORDS
AVAILABLE FOR
PATIENT SUCCESS
CIAT WORKSHEET
MORE CIAT CARDS
CIAT CARDS
WRITTEN SUPPORTS
FADED
WITH PATIENT
MASTERY
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Clinician responses
verbal with supports
“NO”
“STOP”
“WAIT”
MAY INCLUDE RHYMING
WORDS;
CATEGORY WORDS;
EVERYDAY SITUATIONS
PRIMING THE SYSTEM
CIAT PLUS
• CARDS WITH WRITTEN WORDS
• LONGER SYNTACTIC
CONSTRAINTS
• “Mary, may/can I please have
two red shirts”
• “Susan, I do not have two red
shirts”
SPECIFIC SYSTEM OF
CUES
YOU ARE GOING TO
SAY______.
GET READY….
HERE WE GO….
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IMITATION WITH
DIRECT MODEL…..
“SAY……..”
ALLOW
APPROXIMATIONS
CLOZE PASSAGE
WITHOUT A PHONMEIC
CUE
“THE GRASS IS ……..”
CLOZE PASSAGE WITH
A PHONEMIC CUE
“THE GRASS IS G…….”
QUESTION
“WHAT COLOR IS
GRASS?”
FINALLY
“WHAT IS THIS?”
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PROMPT
Prompts for
Restructuring Oral
Muscular Phonetic
Targets
tactile-kinesthetic approach
that uses touch cues to a
patient’s articulators (jaw,
tongue, lips) to manually
guide them through a
targeted word, phrase or
sentence
PATIENT SELECTION
CRITICAL TO SUCCES
FLUENT APHASIA
• Press of speech
• Decreased auditory comprehension
• Decreased internal feedback
• Can convince others they are
communicatively intact
They initially present as
much more
communicative:
generic phrases,
cocktail speech
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PRESS OF SPEECH
• Decreases due to the turn
taking, specific behavioral
responses practiced hundreds
of times
CIAT IMPROVED
OUTPUT OF
CONTENT
INFORMATION
AND
LENGTH OF
UTTERANCES
NON FLUENT APHASIA
Both press of speech and
auditory comprehension
are address through series
of specific verbal
responses
Both have some level of
intact comprehension
and can respond
successfully to various
level of redirects
FRUSTRATED = NO TALKING
Often experience deficits in
motor planning leading to delay
in verbal responses, which
allows others to step in and
take over verbal expression.
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CIAT TEACHES
SPECIFIC
SEQUENCED
VERBALIZATIONS
MOST STUDIES REPORT
NOT ONLY IMMEDIATE
GAINS AFTER AS
LITTLE AS 2 WEEKS
BUT ALSO…..
AND AS LONG AS …..
MAINTENANCE
OF THOSE
SKILLS
•
Not
recommended
for use
with a
Global aphasic
POST TESTING
HIGH TOLERANCE FOR THERAPY
“Reminds me of working in the
mines”
“Doing the same thing over and
over again”
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FAMILY TRAINING
• FAMILY TRAINED TO
COMPLETE CIAT
• UNDER SUPERVISION FOR 2
DAYS
• INDEPENDENT COMPLETING
PROGRAM FOR 8 DAYS
THERAPIST AVAILABLE FOR ANY
CONCERNS
COMMUNICATIVE
EFFECTIVENESS INDEX
(CETI)
BOTH GROUPS EQUALLY
IMPROVED ON STANDARIZED
LANGUAGE ASSESSMENT
MEINZER, STREIFTAU, ROCKSTROH (2007)
Evaluates the quality of everyday
communication via 16 questions
Developed with input
from patients with
aphasia who identified
meaningful
communication
situations
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Those close to the
patient evaluate the
quality of everyday
communication
Please Rate 's ________ ability at...
Getting somebody's attention;
Indicating that he/she
understands what is being said to
him/ her;
Having coffee-time visits or
conversations with friends and
neighbors;
Starting a conversation or
changing the subject;
Starting a conversation with
people who are not close family;
COMMUNICATION ACTIVITY LOG
• RATES THE AMOUNT OF
EVERYDAY COMMUNICATION
FOR 11 ITEMS
• 0= NEVER
• 6-AS OFTEN AS BEFORE THE
STROKE
Being part of a conversation when
it is fast and there are a number of
people involved;
Participating in a conversation
with strangers.
AFTER CIAT BOTH
PATIENT AND
SIGNIFICANT OTHERS
REPORTED AN
INCREASE IN THE
AMOUNT OF EVERYDAY
COMMUNICATION
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NOTES SUCCESSFUL
COMMUNITY INTERACTIONS
Games that can promote CIAT
THERAPY
APP
Bhogal SK, Teasell R, Speechley M. (2003). Intensity of aphasia therapy,
impact on recovery. Stroke.34(4):987-93
Cherney, L. et al. (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, 1282-1299.
Frey, Newman, and Arciniegas, Constraint Induced Aphasia Therapy,
International Brain Injury Association (2012).
Kurland, K. et al. (2012). Constraint 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, S65-S87.
Lomas, J. et al (1989), The Communicative effectiveness index:
development and psychometric evaluation of a functional communication
measure for adult aphasia. Journal of Speech and Hearing Disorders, 54,
113-124.
Kleim, J.A., &Jones, T. A. (2008) Principles of experience-dependent
neural plasticity: Implications for rehabilitation after brain damage.
Journal of Speech-Language Hearing Research, 51 (Suppl.) S225-S239.
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2/5/2016
Meinzer, Marcus, et al. First Decade of Research on
Constrained-Induced Treatment Approaches for Aphasia
Rehabilitation. Achieved of Physical Medicine and
Rehabilitation, 93, 35-45, January, 2012.
Szaflarski, J., Ball, A. & Reichhardt. (2008). Constraintinduced aphasia therapy stimulates language reconvery in
patients with chronic aphais after ischemic stroke. Medical
Science Monitor, 14 (5), 243-250.
Meinzer, M. et al. Long Term Stability of Improved
Language Functions in Chronic Aphasia after Constraint
Induced Language Aphasia Therapy. Stroke, 36, 1462-1466,
2005.
Vinson, Betsy Partin. (2012). Language Disorders Across the
Lifespan, Clifton Pak, NY: Delmar.
Pulvermuller, F.B. et al. (2001). Constraint-induced therapy
of chronic aphasia after stroke. Stroke, 32, 1621-1626.
www.promptinstitute.com
www.constanttherapy.com
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