Constraint Induced Aphasia Therapy: Volunteer-led, unconstrained and less intense delivery can be effective

Abstract

Abstract.BACKGROUND: Constraint Induced Aphasia Therapy (CIAT) has been shown to be effective in the treatment of aphasia, but clinicians have expressed concern regarding how far CIAT is practical to implement in clinical practice. OBJECTIVE: To determine whether CIAT delivered in a less-intense, lower dose, reduced constraint and volunteer-led format could produce positive outcomes in people with chronic aphasia. METHODS: Two groups were run, each with two people with chronic aphasia. Treatment involved a standard CIAT cardexchange game, supplemented by a home activity. Spoken language was required for responses but alternative modalities of communication were also permitted. Each group was led by a trained volunteer, lasted 90 minutes and was delivered twice a week for four weeks. RESULTS: Three of the four participants showed significant improvements in target word retrieval following treatment. No significant improvements were observed for untreated stimuli or language tasks. Two participants showed increases in the elaboration of their responses, and the same two showed an increase in the frequency with which they engaged in communication activities. CONCLUSIONS: Clear gains in performance were observed for the majority of people with aphasia who participated in a less intense format, considerably lower dose and less constrained form of CIAT led by trained volunteers. This suggests that this 'clinically realistic' service delivery model for CIAT could be added to the clinical repertoire of speech pathologists.

Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials

“…Usually, CIAT was delivered via a therapeutic group. Also, literature provided the evidence about the feasibility of trained laypersons-given CIAT [ 41 ], thus, an increasingly number of studies have introduced trained students or volunteers into the therapeutic groups [ 30 , 36 ], which make it more feasible in rehabilitation settings by saving the human powers. Moreover, recent studies showed that the CIAT implemented at acute phase and subacute phase [ 27 , 31 , 35 ] was tolerable by stroke patients.…”

“…Also, a study compared the CIAT-distributed (constraint and low intensity) and conventional therapy (unconstraint and low intensity), and showed no statistical difference in any outcomes [ 35 ]. Some studies with pre-post design reported the effect of less constraint or unconstraint [ 36 , 37 ]. However, the effect from constraint was found by some study, for example, a case study comparing with constraint and unconstraint therapy, the language performance was in favor of constraint group, which also was associated with the change in fMRI [ 24 ].…”

“…The main controversy is whether the “constraint” and “high-intensity” are useful. Some studies showed that CIAT with less constraint and less intensity still had the similar effect on post-stroke chronic aphasia [ 36 , 37 ]. A study comparing the intensive and distributed speech therapy gave a conclusion that intensive speech therapy may be not better than distributed speech therapy with the same dosage [ 38 ].…”

Playing a team game improves word production in poststroke aphasia

“…Actively discouraging alternative forms of communication such as gestures does not seem crucial. Relatively unconstrained versions of CIP (where gestures are not prevented) have also been found to be effective (Difrancesco et al, 2012;Nickels & Osborne, 2016;Stahl, Mohr, Dreyer, Lucchese, & Pulvermüller, 2016) and as effective as constrained versions (Kurland, Pulvermüller, Silva, Burke, & Andrianopoulos, 2012). Moreover, a positive impact of gesture on naming has been noted by some studies (Frick-Horbury & Guttentag, 1998;Morsella & Krauss, 2004;Rose, 2013).…”

“…These protocols share the following defining characteristics: (1) Treatment is delivered in small groups (up to three patients); (2) practice is strictly focused on a verbal, spoken output with other forms of communication either not practiced or actively discouraged (constrained); (3) treatment is intensive where intensity refers to the therapy being delivered both with a high-dose and in a compact way (massed rather than distributed practice); (4) treatment is focused on word production (picture naming); (5) treatment involves shaping, where word production is practiced repeatedly, with different carrier sentences, and different degrees of facilitation; (6) naming is promoted in the context of social requests as part of a card game (Go Fish) where participants ask other participants for matching cards. CIP have received a lot of attention because studies have shown benefits for treated words and, occasionally, improvements on standardized tasks (e.g., Carpenter & Cherney, 2016;Pulvermüller et al, 2001; for a review, see Zhang et al, 2017; but also see for negative results-Attard, Rose, & Lanyon, 2012;Hameister, Nickels, Ca, & Croot, 2017;Kurland, Stanek, Stokes, Li, & Andrianopoulos, 2016;Nickels & Osborne, 2016). Which elements are responsible for the success of CIP, however, remain unclear.…”