Vol. 14 Issue 40
Constraint-Induced Therapy for Aphasia
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. However, they may no longer satisfy the requirements of their insurance companies for continued therapy to be covered if they fail to progress rapidly enough within a traditional therapy schedule of 30- to 60-minute treatments three to five times per week.
Constraint-induced (CI) therapy has been used by physical and occupational therapists to help patients regain the use of an arm or leg affected by stroke. This concept has been adapted in speech-language pathology as Constraint-Induced Aphasia Therapy (CIAT), which seeks to reorganize the language areas of the brain damaged by stroke.
In an environment of decreasing 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 and dependent, 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 when they reach a plateau following a few weeks or months of traditional therapy. Treatment is more effective when provided more frequently and for longer periods at a time rather than in shorter treatments spread out over a longer time, such as in traditional therapy schedules, a recent study has shown.1
Constraint-induced therapy was developed by Edward Taub, PhD, from the University of Alabama. The approach seeks to overcome the "learned non-use" that results from patients with stroke experiencing failure during their initial attempts to use an affected extremity. Eventually, the new pattern of using only the unaffected or less affected side becomes so strong that the patient no longer attempts to use the affected side.2
To overcome learned non-use, therapists constrain the use of the "good" side so tasks must be completed using the affected extremity. Treatments are intense and frequent, lasting six hours a day five 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 this 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. 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 parts of their 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.3-5 While a German study concluded that CI therapy for aphasia is effective, few, if any, programs have used the principles to treat expressive aphasia.6
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. As a result, the brain is forced to adapt and find an alternate way to express the idea through verbalization and spoken words.
Patients in the program receive treatment three-and-a-half hours a day five days a week for at least two weeks. Homework assignments each night and on weekends continue the language stimulation. Constraining compensatory strategies combined with extensive and frequent treatments are thought to have the greatest effect on how much progress a patient achieves.
Without the typical 30- to 60-minute time limit, treatment can focus on restoring brain functions rather than using a more compensatory approach that often is necessary with the limited treatment frequency and duration of traditional schedules.
To date, both one-on-one and group treatment have been effective. We have provided CIAT in groups of up to three participants to one therapist, with most reporting a preference for the group setting. They cite increased feedback, examples of how others are progressing with their language, and a feeling of support.
The first two participants made sig.nificant progress during their course of treatment.
The treatment of one participant, who was a year post onset, mainly addressed word finding. After four weeks of treatment, his progress 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.
Increasing fluency, prosody and grammatical completeness was the focus of treatment for a second participant, who was five years post onset. Her progress occurred over the course of two weeks of treatment.
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. Learned non-use gives way to increased communicative confidence and a willingness to communicate in increasingly demanding contexts.
Currently, CIAT is not covered by insurance. In terms of the total number of treatment hours, two weeks of CIAT is equal to approximately three months of more traditional treatment at one hour three times a week. By demonstrating that patients can make more progress in the same number of treatment hours, it is hoped that third-party payers will find this approach to aphasia treatment produces better results in many cases and is cost-effective with regard to such issues as the total cost of treatment, the 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.
1. Bhogal, S.K., Teasell, R., Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34: 987.
2. Taub, E., Uswatte, G., 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: 237-51.
3. Leipert, J., Bauder, H., Miltner, W.H.R., et al. (2000). Treatment-induced cortical re-. organization after stroke in humans. Stroke, 31: 1210-16.
4. Liepert, J., Miltner, W.H.R., Bauder, H., et al. (1998). Motor cortex plasticity during . constraint-induced movement therapy in stroke patients. Neuroscience Letters, 250: 5-8.
5. Levy, C.E., Nichols, D.S., Schmalbrock, P.M., et al. (2001). Functional MRI evidence of cortical reorganization in up. per-limb stroke hemiplegia treated with constraint-induced movement therapy. American Journal of Physical Medicine and Rehabilitation, 80: 4-12.
6. Pulvermuller, F., Neininger, B., Elbert, T., et al. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32: 1621.
• Musso, M., Weiller, C., Kiebel, S., et al. (1999). Training-induced plasticity in . aphasia. Brain. 122: 1781-90.
• Small, S.L. (2000). The future of aphasia treatment. Brain and Language, 71: 227-32.
Jennifer Brown is on staff at Advanced Recovery Rehabilitation Center in Sherman Oaks, CA. She can be contacted at firstname.lastname@example.org.