Communication: it plays a huge role in our everyday lives. The brain is a fundamental component for communication as it is composed of thousands of pathways that contribute to speech and language abilities. Damage in the brain, post stroke, triggers the process of diaschisis, meaning circuits are rapidly rerouting, and the brain has begun adjusting to the new norms. Oftentimes, trauma from a stroke results in acquired disorders of language and/or cognition. One of the most common acquired disorders, secondary to stroke, is aphasia. Aphasia is identified as an “acquired impairment of the cognitive system for comprehending and formulating language, leaving other cognitive capacities intact” (M. Williams, personal communication, 2019).
Aphasia is known to impose devasting effects that impair the ability to communicate with loved ones, co-workers, strangers, and any other daily endeavors that encourage conversation. In addition, social interaction and independence decrease. Social interaction and independence are two extremely important factors that foster a healthy lifestyle. Fortunately, there are several compensatory and restorative therapeutic approaches that enable patients to recover from speech and language deficits from aphasia. One in particular is Constraint Induced Aphasia Therapy (CIAT). Credible research has shown that CIAT increases restorative function and enables patients that have suffered stroke to recover back into their normal daily activities.
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CIAT is a highly intensive restorative approach designed for patients with aphasia secondary to stroke. CIAT is an evidence-based practice that is “proven to be effective in patients with subacute and chronic forms of aphasia” (Bley et al., 2017). The intensity and process of rehabilitation are addressed based upon the severity and classification of aphasia as identified by formal and informal assessment measures, clinician expertise, and trustworthy research. The focus of rehabilitation is geared towards increasing verbal language by retraining the language pathways in the brain. Ultimately, the main goal is to regain functional expressive communication skills and carry them over into real world settings.
“In 2001, CIAT was introduced as a new therapeutic approach involving constraint, shaping, and massed practice” (Pulvermueller et al., 2001). CIAT was developed from constraint induced movement therapy (CIMT) as introduced by Dr. Edward Taub (M. Williams, personal communication, 2019). Originally, the CIMT restorative therapy approach was utilized for patients in the physical therapy setting. The goal was to stimulate movement by taking repetitive and intensive measures. The CIMT approach suggests, “that the nonuse of a paretic extremity is learned during the early period after stroke and this nonuse can be overcome by creating situations that induce patients to reuse the neglected extremity” (Meizer et al., 2007). A typical session in the therapy room would consist of continuous movement in areas of weakness while, simultaneously, restricting movement to the areas unaffected by the stroke. Intensity of movement is increased as patients improve this idea was sprung forward specifically targeting the brain for language recovery
“CIAT targets the oral-verbal modality of language using shaping, scaffolding, and reinforcement” (Mozeiko et al., 2016). With stroke induced aphasia, it is common for patients to utilize strategies that compensate for their verbal communication (e.g., gestures, facial expressions). To combat the compensatory, the idea of CIAT is to stimulate the language centers in the brain which forces verbal communication and gives each patient their skills back. This approach implies that “the brain is like a muscle, the more you exercise it, the better it gets” (M. Williams, personal communication, 2019). Speech Language Pathologists (SLPs) are qualifying professionals that provide treatment services. As previously stated, their patients are restricted to the use of compensatory strategies. CIAT therapy can be conducted in a variety of settings like in a group or one on one between the SLP and patient.
The most commonly addressed approach takes place in group settings. In a group session, patients are given a deck of cards with a variety of different visuals on each card. There are different levels of visual images on the cards which serve as an example of a scaffolding tool as it shapes learning into chunks and enables patients to achieve their verbal output goals. Patients are instructed to ask questions and respond with full sentences. Any form of compensation such as gestures or facial expressions are prohibited. As an additional preventative measure to constrain nonverbal language, pop up boards are placed in between each individual. This added stimulus prevents each individual from nonverbal communication with their peers. SLPs model behavior that promotes expressive language. The aim is to communicate effectively and exchange the cards by answering questions with full sentences.
Expressive language is drilled between group interactions through the card game, while compensatory strategies to communicate, which, for this approach, is nonverbal communication, are restricted. Additionally, the intensity of language output is increased as patients show improvement. However, “research has shown that a common problem established in current therapy approaches is the lack of generalization of treatment effects to improve communication in everyday life” (Meinzer et al., 2007). In other words, there is a lack of carryover of regained language skills from therapy into real life settings. On the other hand, a therapy approach like CIAT is beneficial because it creates a social environment which promotes real world situations.
Furthermore, extended research has analyzed the effectiveness of CIAT through more specific measures of intensity and rehabilitation. Woldag et al. (2017) conducted a three armed, single blinded, randomized controlled study with 60 participants. These participants were split into three groups (the arms): CIAT, control group, and a conventional communication group. The CIAT and conventional communication groups received at least three hours of intensive therapy services. The control group received daily individual therapy services for under an hour; in addition to meeting the requirement of attending four group therapy sessions. Treatment was administered by two skilled SLPs. This trial was conducted for 10 days and administered to patients post stroke. Results concluded, “data showed significant posttherapy improvements from both groups (CIAT & Conventional communication group). The CIAT group showed a measurably better posttherapy performance in the secondary endpoint. These conclusions are in line with growing evidence that patients generally profit from an intensive training schedule” (Woldag, et al 2017).
As demonstrated in these results, intensity of treatment is suggestive towards being highly important for retraining the brain. “Generally, treatment is 3 hours each day over the duration of 10 days” (M. Williams, personal communication, 2019). With the appropriate measures of applied intensity, the brain successfully adapts to these changes. It follows the same strategy as overloading with weightlifting. A weightlifter does not increase muscle mass by lifting the same five pounds each week. Intensity is increased with progression of heavier weights. To avoid reaching a plateau, progressive intensity is crucial for brain restoration.
In addition to these compelling findings, more research performed by Mozeiko, et al. confirmed suggestive evidence from a double administration of CIAT stating that the “translation to the re-establishment of language in the injured brain follows that increased accurate oral-verbal productions will result in neural and behavioral changes” (Mozeiko, et al., 2018). There were four patients involved in this study and they were diagnosed with aphasia from a stroke.
Experimentally designed as a modified multiple baseline in conjunction with a multiple probe technique (Thompson, 2006), results of this study were examined with individual analysis in single subject design format. Treatment protocol took place in two phases with all four participants adhering to the following sequence: Treatment I and Treatment II. Treatment I received therapy five days out of the week for three hours over the course of two weeks and was modeled in a group setting after the card game Go Fish. Before Treatment I began, all four participants were administered the Boston Naming Test, Western Aphasia Battery-Revised, and baseline probes were obtained to determine a starting point. After this phase was completed, there was a five-week break of CIAT, but continued measures with probing were taken (probing, post treatment I standardized test administration: WAB-R and BNT). Treatment II consisted of the same method and procedures as Treatment I. After treatment II was completed, final assessment measures were obtained with standardized tests and probing. Overall, results indicated, “gains were observed for all four participants despite the wide range of severity, including participants who tested at the mild end of the aphasia spectrum” (Mozeiko, et al., 2018).
In conclusion, the language centers in the brain play a massive role in daily communication. There are multiple different treatment options that SLPs use as gateways for patients to regain their speech and language abilities. When a stroke occurs, the brain is critically impacted, which can cause devasting life changes. Aphasia is a specific language impairment that is neurobiological and commonly occurs secondary to stroke causing speech and language deficits. Applying evidence-based practice provides the most beneficial care for patients suffering from aphasia secondary to stroke. Current research has identified that CIAT, developed from CIMT, is a compelling evidence based practiced restorative therapeutic technique for patients striving to regain expressive language skills. CIAT applies intensive measures for rehabilitation that enable the opportunity for functional restoration of speech and language. Communication: it plays a huge role in our everyday lives.
References
- Meinzer, M., Elbert, T., Djundja, D., Taub, E., & Rockstroh, B. (2007). Extending the Constraint-Induced Movement Therapy (CIMT) approach to cognitive functions: Constraint-Induced Aphasia Therapy (CIAT) of chronic aphasia. NeuroRehabilitation, 22(4), 311-318.
- Mozeiko, J., Myers, E., & Coelho, C. (2018). Treatment Response to a Double Administration of Constraint-Induced Language Therapy in Chronic Aphasia. Journal of Speech, Language, and Hearing Research., 61(7), 1664-1690.
- Williams, M. (2019). Lecture on Aphasia Therapy. Personal Collection of M. Williams, University of South Dakota, Vermillion, SD.
- Woldag, H., Voigt, N., Bley, M., & Hummelsheim, H. (2017). Constraint-Induced Aphasia Therapy in the Acute Stage: What Is the Key Factor for Efficacy? A Randomized Controlled Study. Neurorehabilitation Neural Repair, 31(1), 72-80.
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