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Aphasia Treatment Evidence-based Practice – The State of the Evidence. Janet Patterson, Ph.D., CCC-SLP VA Northern California Healthcare System Martinez CA and California State University East Bay Hayward CA. Session Two. Activity/Participation-based Treatment Treatment Delivery

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aphasia treatment evidence based practice the state of the evidence

Aphasia TreatmentEvidence-based Practice – The State of the Evidence

Janet Patterson, Ph.D., CCC-SLP

VA Northern California Healthcare System

Martinez CA


California State University East Bay

Hayward CA

session two
Session Two

Activity/Participation-based Treatment

Treatment Delivery

Emerging Treatment Techniques



  • Identify evidence for activity/participation-based treatment techniques
  • Identify evidence for emerging treatment techniques
  • Identify considerations for successful treatment outcome
outcome measures
Outcome Measures
  • Test results
  • Connected speech
    • CIUs (Brookshire & Nicholas, 1993)
    • Content units (Yorkston & Beukelman, 1980)
  • Perceptual data
    • Interview with PWA, family, friends or associates (Lomas et al., 1989)
  • Activity reports and surveys
    • ADLs, social occasions, conversation, job success
  • Quality of life (Hilary, Byng, Lamping & Smith, 2004)
life participation approach to aphasia
Life Participation Approach to Aphasia

Core 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)

activity participation based treatment techniques9
Activity/Participation-based treatment techniques
  • Group treatment
  • Conversation participation
  • Treatment for caregivers or conversation partners
  • Personal narratives; scripts
  • AAC
types of group treatment
Types of Group Treatment
  • Goal-directed
    • Conversation participation (Simmons-Mackie, 2000; Vickers, 1998)
    • Specific linguistic goal
    • Cooperative 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)

Evidence, ES and Conclusions

Effect Sizes for Group vs. Individual Treatment

--- RCTs ---

Kelly, Brady, Enderby, 2010


Change Scores and Total Number of Participants for Studies of Group Treatment

Change Score

Salter, Teasell, Bhogal, Zettler & Foley (2010)



    • Inconsistent data supporting effectiveness of group treatment over individual treatment
      • Limited support for social groups and language change
  • Other published studies
    • Moderate support for group treatment and language change
    • Varying methodology and outcome measures

Anecdotal 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
    • People “vote with their feet”
      • Number of aphasia groups increasing
      • Expanded variety of group types
        • Book group, artistic expression, theater group, exercise group, choral group
script training
Script Training
  • Client and clinician create short, relevant scripts
  • Repetition 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
supported conversation and partner training
Supported Conversation and Partner Training
  • Communicative competence of a PWA can be uncovered by a skilled partner
    • Typically family members or close friends
    • Consider layers of training
  • Partner changes

behavior so PWA

will change

Armstrong & Mortenson

treatment techniques
Treatment Techniques
  • PACE Promoting Aphasics’ Communicative Effectiveness (Davis & Wilcox, 1985)
    • Collaborative exchange of information
  • RET Response Elaboration Training (Kearns, 1985)
    • Expand utterance content
  • Conversational 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
evidence es conclusions
Evidence, ES, Conclusions
  • Script training
    • Approximately 15 studies
      • PWA have variable characteristics
        • Mild to moderate aphasia
        • Typically 6 months or more post onsets
      • Outcomes
        • Improved production of practiced scripts
        • Some generalization to other communication situations
        • Slightly increased speaking rate
        • Error reduction
    • Insufficient evidence for systematic review - yet

Review of partner training studies

    • PWA – variable characteristics
      • Most lived independently
      • 4-178 MPO
      • Mild to moderate to severe aphasia
      • Comprehension and/or expression deficits
    • Partners
      • Primarily family members or usual partners
    • Approaches
      • Partner change was goal
      • Facilitate desirable behavior or inhibit undesirable behavior

Turner & Whitworth , 2006; http://www.asha.org/members/reviews.aspx?id=7499



    • Improved interaction
      • More successful conversation turns
      • Fewer interruptions
      • Fewer turns devoted to repair
    • Successful social validation
    • More accurate sense of partner’s aphasia
    • Maintenance and generalization of behavior

Turner & Whitworth, 2006


Moderate (RCT) to limited (small studies) evidence supporting conversation and partner training

  • Considerations
    • Individual personalities of PWAs and partners
    • Conversational style

Turner & Whitworth, 2006

treatment techniques24
Treatment techniques
  • PACE and RET
    • Several studies investigating each treatment
    • Primarily positive results reported
      • Trained items
      • Untrained items
      • Generalization items
    • No systematic review of the techniques
      • Single subject design studies

Conversational Coaching and Reciprocal Scaffolding

    • Few studies investigating each treatment
    • Primarily positive results reported
      • Some generalization reported
    • No systematic review of the technique
      • Single subject design studies

Moderate (small studies) or inconsistent (RCTs) support for group treatment.

Modest support for script training (multiple forms).

Modest support for communication partner training.

Modest support for PACE and RET.

intensity and dosage
Intensity and Dosage
  • Theories supporting treatment intensity
    • Hebbian cell assemblies (Hebb, 1949)
    • Education learning theory http://www.emtech.net/learning_theories.htm
    • Neuronal plasticity (Kleim & Jones, 2008)
    • Dosage (frequency, intensity, duration)
  • Early aphasia treatment research (Darley, 1972)


ES for Outcome Measures for studies investigating intensity of treatment


Cherney, Patterson, Raymer, Frymark

& Schooling, 2008;

Frymark, Cherney, Patterson & Raymer, 2010

errorless reduced error learning
Errorless (Reduced Error) Learning
  • Theoretical foundation
    • Initially demonstrated in animal learning
    • Memory rehabilitation
    • Error behavior can be self-reinforcing > eliminate
  • Contrast
    • Errorless learning
      • Error elimination
      • Error reduction
    • Errorful learning (cueing hierarchy)
      • Errors not controlled

Review of 27 studies

  • 91 outcome measures at three times
    • Immediate benefit = 78% yes; 25% no
    • Follow up benefit = 38% yes; 27% no
    • Generalization = 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)

neuronal plasticity
Neuronal Plasticity

Principles of experience-dependent neural plasticity

Time matters

Salience matters

Age matters



  • Use it or lose it
  • Use it and improve it
  • Specificity
  • Repetition matters
  • Intensity matters

Kleim & Jones, 2008; Raymer et al., 2008; Raymer, Maher, Patterson & Cherney, 2007


Experience-dependent neuronal plasticity is the basis for learning and influences recovery

    • In the presence of treatment
    • Without treatment as one navigates the world
  • Research aimed at translation of neuroscience to neurorehabilitation
    • Neuroimaging studies
    • Dosage
    • Application of principles individually and in combination

Greater intensity may be more effective than lesser intensity.

Individual variation for aphasia type, TPO and task.

Errorless, reduced error and errorful treatment techniques are effective.

Individual variation for aphasia type, TPO and task.

Principles of neuronal plasticity positively influence treatment effectiveness.

emerging treatment techniques
Emerging treatment techniques
  • Pharmacotherapy
  • Computer-aided treatment
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Transcranial Direct Current Stimulation (tDCS)
  • Epidural cortical stimulation
  • Drugs investigated in RCTs
    • Piracetam
      • Weak evidence in support but concern for side effects
    • Dextran – insufficient evidence
    • Bifemelane - insufficient evidence
    • Bromocriptine - insufficient evidence
    • Idebenone - insufficient evidence
    • Piribedil - insufficient evidence

Greener, Enderby & Whurr, 2010


Additional studies of drugs 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

computer based treatment
Computer-based Treatment
  • Not so new but re-emerging technique
    • As primary treatment (Doesborgh, van de Sandt-Koenderman, Dippel, van Ahrskamp, Koustall & Visch-Brink, 2004; Cherney, Halper, Holladn & Cole, 2008)
    • Practice of skills learned in treatment
    • Telehealth
  • Strong evidence in favor of improvement at impairment level
  • Limited evidence for generalization functional communication

Salter, Teasell, Bhogal, Zettler & Foley, 2010

cortical stimulation
Cortical stimulation
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
    • How it works
      • Noninvasive; Cause depolarization of neurons
      • Place electrodes on scalp at regions of interest
        • R perisylvian area or RH Broca’s area homologue
      • Induces weak electric current in rapidly changing magnetic field
      • Facilitates neuronal activity
    • Some evidence in favor
      • Patients with chronic nonfluent aphasia
      • Improvement in naming
      • Some improvement in spontaneous speech

Salter, Teasell, Bhogal, Zettler & Foley, 2010; Martin, Naeser, Ho, Doron, Kurland, Kaplan, Wang, Nicholas, Baker, Alonso, Fregni & Pascual-Leone, 2009


Transcranial Direct Current Stimulation (tDCS)

    • How it works
      • Application of weak electrical currents (1-2 mA) to modulate the activity of neurons
      • Polarity determines whether excitability is increased or decreased
    • Limited evidence in favor
      • Patients with chronic nonfluent aphasia
      • Improvement in naming

Salter, Teasell, Bhogal, Zettler & Foley, 2010;

Baker, Rorden & Fridriksson, 2010


Epidural Cortical Stimulation

    • How it works
      • Impulse generator implanted subclavicularly
      • Epidural electrode embedded over dura of target cortical area
      • Neurons stimulated; perhaps to rewire themselves
    • Limited evidence in favor when used with behavioral treatment
      • Chronic nonfluent aphasia

Cherney, 2009; Cherney & Small, 2007


Inconsistent evidence supporting pharmacological treatment.

Some favorable evidence in conjunction with behavioral 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.