Robert C. Marshall, Ph.D. University of Kentucky Lexington, KY, U.S.A.

Robert C. Marshall, Ph.D. University of Kentucky Lexington, KY, U.S.A.

Robert C. Marshall, Ph.D. is the sole presenter of this seminar. He has no financial or non-financial interest relevant to the topic of this presentation.

Chronic Broca s aphasia + severe AOS; ischemic LH stroke in insula 7 years post onset No physical deficits WAB AQ = 48; good comprehension Communicates single word writing; drawing; hint and guess; stereotypic utterances Back to work as a dentist less than 1 year post onset

U.S. Health care system

When spontaneous recovery ends? 2 weeks post onset 3 months post onset When patient returns home from the hospital to face a lifetime of living with aphasia

General support Communication support Spontaneous recovery

The hospital environment Doing for the patient Trained personnel Assistance and guidance Ability to talk to persons with aphasia

Acute care support, guidance, counseling, and brief evaluation Rehabilitation hospital most of speech and language therapy is delivered here Outpatient depending on funding only a few visits

Improvements in speech, language, physical, and mental status due to neurophysiological changes in the patients condition. Begins a few days after onset Greatest in first 2-4 weeks Considered complete by 3 months

PAT While I was in the hospital, knew I was getting better and at first I thought I m going to be all right. A few days later when I still had problems, I thought, well, I ll be almost as good as new. And after I got home and I still wasn t back to normal, I thought wow, this is really serious stuff. JAN I had no idea how our lives would be disrupted when my husband was in the hospital. When I brought him home, it was necessary to totally reconfigure our lovely home. My husband could not go up and down the stairs where the bedrooms were. We had to convert our dining room into his bedroom and our living room into his command center. We never entertained again.

Discharge from hospital Going home Termination of therapy

Is chronic aphasia People with chronic aphasia improve but they don t recover Therapy s goal should be to find a way to help patients and families fit aphasia into their lives to live as successfully as possible with the disorder

1 million people in U.S. have chronic aphasia Cap put on services for outpatient treatment of $1920 per year Dollars shared by speech therapy and physical therapy

ASHA and APT have tried Write your representative! The cap remains

WHAT IS HAPPENING? People with chronic aphasia are willing and near-exclusive participants in aphasia treatment research Results of this research have clearly shown benefits for people with chronic aphasia RESULTS OF RESEARCH Results of aphasia treatment research have not impacted funding for treatment of chronic aphasia in the United States.

1 million people is not that big a number Most people with aphasia get a long quite well All people with chronic aphasia don t want treatment; many live in areas where they can t get to treatment

People with aphasia? they need to complain Aphasia clinicians? need toot your horn Health care Medicare? It s unfair

EARLY POST ONSET PERIOD Spend less CHRONIC PERIOD Spend more

PWA often too ill to participate fully in early post onset therapies Early treatment is abetted by spontaneous recovery and this raises false hopes The hospital environment is a sterile one and mitigates against generalization

FACT Most aphasic stroke patients must spend some time in the rehabilitation hospital to re-establish basic functions. Dealing with eating, toileting, ambulation, and other basics would be difficult as an outpatient QUESTIONS Do basic needs trump communication? Some patients suggest they do? Some clinicians would argue they do not Does research answer this question for us?

Title: A comparison of clinic, home, and deferred treatment for aphasia Method: Ss with aphasia randomly assigned to clinic, home, or deferred treatment for aphasia shortly after ischemic stroke. Treated for 8-10 hours per week for 12 weeks. Outcome measure: Porch Index of Communicative Ability PICA) Results: Patients treated immediately and in clinic and home groups improved significantly more in the 1 st 12 weeks than those in the deferred groups; in the 2 nd 12 weeks when the deferred group received treatment, they improved to the level of the clinic and home groups Conclusion: Patient with aphasia are not harmed by being treated later

Title: A randomized controlled trial on very early speech and language therapy in acute strike patients with aphasia Method: Ischemic stroke patients with aphasia assigned randomly to treatment and control groups at 2 days post onset. Treated patients had Language Enrichment therapy 45 minutes a day from an SLP for 21 days; control patients were not treated Outcome measures: Everyday Language Test and standardized measure Results: Negligible differences between the groups on the two tests Conclusion: difficult to disentangle effects of early treatment and spontaneous recovery

Title: Very early poststroke aphasia therapy: a pilot randomized controlled efficacy trial Method: Randomly assigned patients with acute aphasia to daily aphasia therapy and usual treatment (5-10 minutes of therapy per week) Outcome measures: Western Aphasia Battery and Functional Communication Results: Those getting daily therapy scored 15.1 points higher on the WAB- AQ and 11.3 points higher on the FCP than those in the usual care group. Conclusions: Patients getting more treatment improved more. Early treatment s beneficial

Hospitals charge a lot for speech And language therapy Medicare pays a flat rate Insurance companies pay a % T-man Why do you rob banks? Willy Sutton Because that s where the money is.

Bailout is unlikely Speech is a low-cost service Hospitals are profiting Payers will continue to limit services SLP will not provide Patient will lose

Rather than continue to ration care why not consider delivering care rationally. We have viable options for treatment of people with chronic aphasia.

Scenario 1: a TBI client needing to stay off welfare Scenario 2: A dentist needing to continue his home town practice Scenario 3: Supporting retraining of a sales executive

Research findings Trends in computer use Consumer protection Role of SLP in steering patient and family to the appropriate computer options and in making necessary changes Computer is not last resort or sending the patient off to a room to practice on his own

More than one person at a time Patient has opportunity to communicate with different partners. More speech acts Bring out passion in the clinician You can have a group for anything and everything

Title: Veterans Administration cooperative study on Aphasia: a comparison of individual and group treatment Method: Patients at less than 2 weeks post onset were randomly assigned to group or individual treatment. Ss were treated 8 hours per week for 44 weeks. Outcome measure: Porch Index of Communicative Ability (PICA) Results: Found no differences among subjects getting individual or group therapy on the PICA except on the writing subtests. This was understandable since writing was not addressed in treating the subjects in the group situation. Conclusions: Group treatment fared as well as individual treatment

Title: The efficacy of group communication treatment in adults with chronic aphasia Methods: Subjects with chronic aphasia were randomly assigned to immediate or deferred group treatment. All received 5 hours of communication-focused group treatment per week from a SLP for 4 months. Deferred group participants for waiting for treatment received communication support. Outcome measures: Short form of PICA; WAB-AQ, & CADL at entry, 2-4 weeks later, and at follow up Results: Treated patients had higher SPICA and WAB-AQ; moderately severe patients had higher CADL scores; deferred group caught up to immediate group when treated Conclusions: Group treatment efficacious for people with chronic aphasia

Title: Intensive language action therapy, nee constraint induced language therapy Method: Patients with chronic aphasia are seen in small groups run by a SLP. Therapy occurs 3 hours per day, 5 days per week, for 2 consecutive weeks (30 hours). Therapy is contextually based and relies on language action principles to link language to actions such as requesting, giving, and refusing. Outcome measures: Aachen aphasia test, self reports, brain scans Results: Standardized language tests, brain scan, therapy logs Results: Significant and positive changes on standardized and functional measures; some studies have shown improved language outcomes are accompanied by changes in brain plasticity. Conclusions: Intensive language action therapy is strongly supported by empirical evidence

Conversational therapy Partner training Communicative counseling

Goal: improve the patient s ability to converse with or without support; improve patient s skill and confidence as a conversational participant Specifics: improve information exchange; work on social communication skills needed to participate in a particular social event; may be patient specific Example 1 preparing to attend a 50 year college reunion Example 2 selective use of compensatory strategies at a large Xmas party

Why: PWA spend more time communicating with others; it makes sense Who: family, friends, service providers, etc. Benefits: increasing communication opportunities; promote generalization What use of concrete strategies to support communication; AAC; resolving breakdowns; focus on communication success Research supports partner training Possibilities of partner training

Focus on what s right about the patient and marshaling of strengths rather than fixing what is wrong Accept the challenge and see people with aphasia as interesting human beings Seize counseling moments

We have options for treating people with chronic aphasia (1:1 treatment, computer, group therapy, therapy blast, sociallymotivated treatments) The options have research support to show PWA benefit from the treatments None of the treatments cue aphasia None of the options are easy to deliver in the U.S. because there s no funding to pay for them

Owning up to what aphasia treatment can do Recognizing all treatments are not the same Coming to grips with the cost of treatment Pitch long term perspective Count what counts

We need a definition of aphasia therapy that we can all agree on: Clinicians Payers Physicians Consumers

How much time and preparation is needed on the part of the clinician to deliver the hour of treatment? Is the cost of the treatment justified on the basis of its demonstrable outcomes?

BOB Developing materials Learning about billing Interfacing with staff Learning the procedures for various types of problems Interacting with patients PROBLEM SOLVING GROUP Men with mild aphasia met weekly in a problem-solving discussion group Clinician s job to facilitate, keep order, and document

BOB, THE DENTIST Keeping him on the job Keeping off SSD Providing jobs for his staff Keeping practice open BRIDGE GROUP Opportunity for socialization Mental stimulation Something to look forward to each week

Need to advocate for services over the long haul

The A-FROM model (Aphasia: Framework for Outcome Measurement. Here we see the PWA at the center of the model. The 4 overlapping circles designate the consequences of the impairment (blue), activity limitations (burgundy), participation restrictions (black), and to make it more confusion, the environment (green). Note that all circles also overlap with one another. The point to be made here is that, by working in and/or treating one sphere, the possibility of change in other spheres also exists. For example, if the patient were to resume weekly poker games with his friends (a participation restriction) he would have more opportunities for conversation (language environment), and could reduce his impairment (severity of aphasia) Participation in life situations and perception of aphasia as a barrier to participation Perception of the communication and language Living environment as with support or aphasia barrier, including attitudes Perception of severity of aphasia Personal identity, attitudes and feelings in relation to living with aphasia

Email: rcmarsh@uk.edu

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Holland, A. (2007). Counseling/Coaching in Chronic Aphasia: Getting on With Life. Topics in Language Disorders, 27, 339-350. Kagan, A. Simmons-Mackie, N., Rowland, A. et al. (2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 22-258-280. Laska, A. Kahan, T., Hellblom, A. et al. (2011).A randomized control trial on very early speech and language therapy in acute stroke patients with aphasia. Cerebrovascular Diseases, 1, 66-74. Lyon, J., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., Ryff, C., Coyne, S., and Blanc, M. (1997). Communication Partners: enhancing participation in life and communication for adults with aphasia in natural settings. Aphasiology, 11(7), 693-708.

Marshall, R. (1997). Aphasia treatment in the early post onset period: Managing our resources effectively. AJSLP, 6, 5-12. Marshall, R. (1993). Problem-focused group treatment for clients with mild aphasia. AJSLP, 2, 31-37. Meinzer, M., Rodriguez, A., and Gonzalez-Rothi, L. (2012) First decade of research on constraint-induced treatment approaches to rehabilitation. Archives of Physical Medicine and Rehabilitation. 93, S36-S46. Pulvermuller, F., et al. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621-1626. Rayner, H. and Marshall, J. (2003). Training volunteers as conversational partners for people with aphasia. International Journal of Language and Communication Disorders, 38(2), 149-164.

Wertz, R., Collins, M., Weiss, D. et al. (1981). Veterans Administration Cooperative Study on Aphasia: A comparison of individual and group treatment. Journal of Speech and Hearing Research, 21, 580-594. Wertz. R., Weiss, D., Aten, J. et al. (1987). A comparison of clinic, home, and deferred language treatment for aphasia. Archives of Neurology, 43, 655-658.