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INTENSIVE THERAPY

Author: Joanne Marttila Pierson, PhD

INTENSIVE THERAPY
By Joanne Marttila Pierson, PhD
As seen in ADVANCE for Speech-Language Patahologists & Audiologists, September 19, 2021 issue, Vol. 15 •Issue 38 • Page 17

An intensive therapy protocol should be considered a primary objective for individuals with aphasia. Intensive therapy can achieve significant speech and communication improvements, and successful outcomes are realized regardless of the length of time post the aphasia-causing event.

Positive results are generating greater hope and optimism among people with aphasia, their families and caregivers.

Whether aphasia is caused by a stroke, closed-head injury or disease, outcomes often are tempered with bleak comments from medical professionals such as “This is as good as it is going to get,” “Don’t expect much change,” and “Your lives are going to change forever.” These words can be devastating for patients and caregivers and lead to feelings of hopelessness, despair and depression.

The greater difficulty created by negative perceptions is their impact on recovery efforts. Feelings of hopelessness have a direct connection to an individual’s motivation to put forth the effort necessary for recovery, including entering a therapy program.

Medical professionals and speech-language pathologists play a key role in helping to frame recovery options and generating hope and optimism for improvement. This is why information about the success of intensive therapy is essential for those with aphasia and their caregivers.

A recent study at the Universitat Konstanz, in Germany, demonstrated the success of intensive therapy. The study, while small, offers hope to individuals with aphasia and their families.

Researchers evaluated 27 stroke survivors16 men and 11 women, with an average age of 51who had lived with varying degrees of aphasia for about four years. Study participants were given 30 hours of speech training, three hours a day over a period of 10 days. Improvements were immediate, and they were sustained when reevaluated six months later. Language skills improved in 85 percent of the patients.

The study supports the results many professionals have observed in intensive therapy programs such as the Residential Aphasia Program (RAP) at the University of Michigan. The year-round program, the oldest in the nation, attracts people from across the United States and other countries. The intensive six-week therapy regimen includes 23 hours of therapy per week, with 15 hours of individual therapy, five hours of group therapy, and three hours of computer-assisted training.

Twelve to 15 individuals with aphasia attend each of the six-week RAP sessions, working individually and in group settings with speech-language pathologists. The program includes art and music therapy, as well as social programs such as dinners, theater outings and baseball games.

Many who attend RAP come back several times for additional sessions due to their success and improvement. Some have been to as many as eight individual six-week sessions.

Intensive therapy generates positive outcomes for RAP participants. For example, Bob Virden, 77, now has the confidence to answer the phone, something he was reluctant to do before he entered the program. The Kansas City resident had his first stroke in 1998, followed by two strokes last year. He now speaks clearly, although he sometimes struggles to retrieve the exact words he wants to say.
“RAP is inspiring,” said Virden. “The one-to-one therapy sessions were helpful, and I liked music therapy.”

A retired attorney, Virden owns several buildings and likes to stay involved in supervising them. Because he was struggling with some of the terminology, therapists incorporated key words into his therapy. He now looks forward to being able to communicate more effectively with his business partner.

Considerable bonding occurs between clients and caregivers who attend the sessions, reported his wife, Dorrie Virden. “It was one of the most impressive and moving experiences I have ever had.”

Lindsay Rahl, of Chesapeake, VA, participated in two six-week sessions during 2004 and will participate in another six-week session this fall. Rahl, 50, had a stroke two years ago.

“It was during our first session at RAP that we recognized the significant progress she was making, far beyond what she was able to achieve at home in a traditional outpatient therapy setting,” her husband recalled. “During our second session, we saw even greater progress, with significant improvements in both comprehension and verbal ability.”

Sixteen-year-old Jacob Nettles, of Nederland, TX, just completed his second visit to RAP and is scheduled to return for additional sessions later this year.

“RAP’s intensive program gives Jacob more focus,” his father reported. “The variety of programs, including one-on-one therapy, group, music, art and computer sessions, provides a variety of therapies that keep him motivated.”
For people with aphasia and their families and caregivers, intensive therapy may be the most important step in achieving significantly improved communications skills.

For More Information
Residential Aphasia Program, University of Michigan, (734) 764-8440, online: Residential Aphasia Program (RAP) .

Joanne Marttila Pierson, PhD, is associate director of the Residential Aphasia Program at the University of Michigan.

Stroke Treatment

Author: Adance for Speech-Language Pathologists & Audiologists

An experimental treatment that spares disability from acute stroke may be delivered much later than the current three-hour treatment standard. This potential advance is needed to benefit more patients.

Researchers at the University of South Florida (USF) found that human umbilical cord blood cells administered to rats two days following a stroke greatly curbed the inflammatory response of the brain, reducing the size of the stroke and resulting in greatly improved recovery. The inflammatory response to injury from stroke peaked 48 hours after the brain attack, which was when intravenous delivery of the cells appeared most beneficial.

“We were very surprised,” said principal investigator Alison Willing, PhD, a neuroscientist at the USF Center of Excellence for Aging and Brain Repair. “In some animals the stroke initially damaged half the brain, but they were functioning normally after treatment with the cord blood cells. These findings show we are able to rescue neurons at a time when most research suggests they are already dead.”

Dr. Willing presented the preliminary findings at the annual meeting of the Society for Neuroscience on Nov. 12 in Washington, DC.

The only drug currently approved for ischemic stroke treatment is tissue plasminogen activator (tPA), which breaks up blood clots. However, tPA must be given within three hours following a stroke to be effective, and few patients arrive at the hospital quickly enough to receive it. Even when patients meet this criteria, smaller hospitals often lack ready access to computed tomography (CT), which can rule out a hemorrhagic stroke. The drug can worsen this less common type of stroke.

“New and more flexible treatments are needed to help more patients,” Dr. Willing said. “Cord blood treatment in rats is successful in alleviating, even eliminating, the disabling effects of both ischemic and hemorrhagic stroke. What’s more, the treatment can be delivered much later than the current therapeutic window.”
The USF study challenges the notion that nerve cells inevitably die quickly in the core region of the brain most severely deprived of oxygen and nutrients during stroke. The researchers suggest that many succumb over several days through apoptosis.

“This delayed death would permit more time to deliver neuron-sparing treatments than originally thought,” Dr. Willing said. Vol. 15 •Issue 47 • Page 5

For more information regarding the important research being done by the University of South Florida, please Click Here

Author: Eric Vohr

In the study, Daniel Hanley, a professor of neurology at the School of Medicine, demonstrated that rates of continued bleeding and subsequent death can be reduced if the tPA dosage is lowered to 1 milligram.

“We have good evidence that lower doses of tPA not only worked as well as the higher dose but also markedly reduced side effects in regard to bleeding,” Hanley said. “Ten years ago, the mortality rate for this type of stroke was at 80 percent. One year ago, it was 50 percent. In this study, it was 13 percent.”

Hanley presented the study Feb. 18 at the International Stroke Conference, held in Kissimmee, Fla.

An intracerebral hemorrhage — bleeding in the brain — is the only type of stroke without a clearly defined treatment. It occurs in more than 100,000 Americans each year. Up to half of patients die, and those who survive suffer significant disabilities. During such a stroke, blood often extends into the ventricles, small chambers in the brain where cerebrospinal fluid is made, increasing the chances of damage.

In a previous study by Hanley and his group of 26 patients, a 3 milligram dose of tPA could be used safely to treat this type of stroke, reducing the mortality rate to 19 percent. However, continued bleeding was observed in 23 percent of the patients. This new study was designed to find ways to reduce bleeding and further improve patient outcomes.

Researchers studied 16 patients who received either 0.3 milligram or 1 milligram of tPA every 12 hours through a catheter for up to four days or until the ventricles opened. The patient groups were balanced with respect to age, gender, initial stroke severity and demographic characteristics. Results from daily CT scans from this study and the previous study showed that blood clots broke up over the first three days at similar rates for all three doses. Similarly, compared with a placebo, all doses substantially accelerated clot removal. But unlike the patients who received 3 milligram doses, none of the patients who received either 1 or 0.3 milligram doses experienced continued bleeding as a clinically significant side effect. Also, there were fewer deaths in each of the lower-dose groups, suggesting that the lower doses are safer.

To read the complete article, go to John Hopkins University Gazette.

Author: Edward Tobinick, MD

Abstract:
Primary progressive aphasia (PPA) is an uncommon form of progressive dementia for which there exists no established treatment. The underlying pathology may be that of either frontotemporal dementia or Alzheimer’s disease. Increasing evidence suggests that excess tumor necrosis factor (TNF) may play a central role in Alzheimer’s disease. Additionally, excess TNF has been documented in patients with frontotemporal dementia. Excess TNF may therefore represent a therapeutic target in PPA. Etanercept, an anti-TNF fusion protein, binds to TNF, thereby reducing its biologic effect. Emerging evidence suggests that perispinal administration of etanercept may have therapeutic efficacy for Alzheimer’s disease. This evidence, in combination, supports a rationale for the use of perispinal etanercept for the treatment of PPA. This report documents rapid improvement in verbal abilities, beginning within 20 minutes of perispinal etanercept, in a patient with severe PPA. With repeated weekly dosing, sustained improvement at 1 month is documented, with a more than 10-point improvement in the patient’s abilities to perform activities of daily living as measured by a standardized instrument, the Alzheimer’s Disease Cooperative Study-Activities of Daily Living inventory. Rapid clinical improvement in PPA following perispinal etanercept administration may be related to TNF’s role as a gliotransmitter and modulator of synaptic communication in the brain. These results may provide insight into the basic pathophysiologic mechanisms underlying PPA and related forms of dementia and suggest the existence of novel, rapidly reversible, TNF-mediated pathophysiologic mechanisms in both PPA and Alzheimer’s disease. Further study of this therapeutic method is indicated.

Introduction:

Primary progressive aphasia (PPA) is an uncommon form of progressive dementia without established treatment. One third of these patients have underlying Alzheimer’s disease pathology, and two thirds have pathology characteristic of frontotemporal dementia.[1] These patients characteristically present with progressive difficulty with language as the most prominent initial manifestation of the disease, which advances in an unrelenting fashion until all language abilities are lost.[2] No effective treatment has been established.[1,2]

Basic science and genetic, epidemiologic, and clinical evidence suggest that excess tumor necrosis factor-alpha (TNF-alpha) may play a central role in the pathogenesis of Alzheimer’s disease.[3-23] In addition, excess TNF has been documented in the cerebrospinal fluid of patients with frontotemporal dementia.[24] Excess TNF may, therefore, represent a therapeutic target in PPA. Etanercept, a recombinant dimeric anti-TNF fusion protein, binds to TNF and blocks its interaction with cell-surface TNF receptors, thereby reducing the biologic effect of excess TNF. Emerging evidence suggests that perispinal administration of etanercept may have therapeutic efficacy in Alzheimer’s disease.[25-29] This evidence, in combination, supports a rationale for the use of perispinal etanercept for the treatment of PPA.

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Author: Dr. Richard Steele

Aphasia in bilingual individuals is an area of growing importance to speech-language pathologists (SLPs) in the United States, according to a 2008 ASHA article by Lorenzen and Murray. Not only is the incidence of aphasia rising steadily — with prevalence projected to double over the next decade — but at the same time the number of bilingual Americans is growing. In the 2000 census, some 47 million persons over age five reported speaking a language other than English at home: English-Spanish bilingualism is most frequent, but sizable numbers of residents speak English as well as Chinese, French, or other languages. Feeding this growth in bilingual populations are both increases in family sizes and the arrival of new immigrants. As a consequence of these and additional factors, SLPs can expect to encounter ever-increasing numbers of bilingual clients with aphasia in their future caseloads.

Meeting the rehabilitation needs of bilingual clients with aphasia raises numerous challenging issues for SLPs:
• Assessing speech, language, and communication deficits in each of the languages
• Determining language-specific rehabilitation wants and needs of individual clients
• Understanding the contexts and purposes of different language uses
• Setting treatment goals appropriately
• Providing services effectively
• Identifying, understanding, and documenting improvements

Since a patient’s aphasic deficits frequently vary in different languages, language-specific responses to therapy can follow divergent paths, and the different languages can interact during treatment. As a result, the communication rehabilitation of bilingual persons is complex and not fully understood.
But while bilingual speech therapy presents fundamental challenges, it also provides important opportunities. Careful studies of rehabilitation in bilingual individuals with aphasia, for example, are helping us to refine our understanding of two crucial, basic issues: (1) whether different languages are represented in the same areas of the brain, and if not, then how; and (2) whether age of language acquisition in bilingualism influences the ways in which the languages are represented in the brain and how they interact. These are questions both of fundamental scientific import and of practical clinical significance. As we improve our understanding of these issues and are better able to characterize bilingual individuals with aphasia, then clinical personnel will be able to better assess deficits, determine needs, provide therapy, understand responses, and follow up after discharge.

Clinical studies to date have provided very preliminary answers. Different languages appear to draw on partially distinct, yet largely overlapping cerebral areas. As a consequence, overall aphasic severity may differ somewhat from language to language and two languages’ subsystems – such as their syntax or lexicon – may be affected somewhat differently. Age of acquisition also appears to influence how languages interact in bilingual individuals. A second language acquired in adulthood may be influenced by the speaker’s first language ¯ resulting, for example, in a foreign accent or unusual word usage ¯ in ways not observed in individuals whose two languages were both acquired during childhood. But work is still at an early stage, and much remains to be done to understand these phenomena in depth. Improved understandings of bilingual aphasia and its clinical management are matters of growing importance, both theoretically and clinically.
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For further reading: Bonnie Lorenzen, Laura Murray. “Bilingual aphasia: A theoretical and clinical review.” American Journal of Speech-Language Pathology, August 2008, vol. 17, no. 8, pp. 299–317.
doi: 10.1044/1058-0360(2008/026)

Call Lingraphica toll free at 1-888-APHASIA (1-888-274-2742) or visit their website at www.lingraphica.com to learn more about a no-obligation trial of the new Lingraphica.

Author: James S. McKinney, MD

New recommendations from the American Heart Association/American Stroke Association on using t-PA between 3 and 4.5 hours after stroke onset .

Recombinant tissue plasminogen activator (t-PA) is FDA-approved for the treatment of acute ischemic stroke within 3 hours after symptom onset. A recent randomized, controlled trial (ECASS 3) demonstrated that intravenous t-PA is safe and effective in patients treated between 3.0 and 4.5 hours after symptom onset (N Engl J Med 2008; 359:1317). Primarily on the basis of this finding, the American Heart Association/American Stroke Association has now issued revised treatment guidelines for acute ischemic stroke that recommend t-PA use up to 4.5 hours after symptom onset.

The guideline authors note that patients eligible for treatment within 3 hours should still be treated according to the AHA/ASA 2007 guidelines. For patients treated between 3.0 and 4.5 hours, eligibility criteria for t-PA treatment are similar to those for patients treated within 3 hours, with four additional exclusion criteria: age >80, oral anticoagulant use (regardless of international normalized ratio), baseline NIH Stroke Scale score >25, or history of both diabetes and prior stroke. The guidelines emphasize avoiding delays in treatment, because the odds of a favorable outcome decline over time.

Read complete article .

Author: Medical News Today

Until recently, scientists believed that, following a stroke, a patient had about six months to regain any lost function. After that, patients would be forced to compensate for the lost function by focusing on their remaining abilities. Although this belief has been refuted, a University of Missouri occupational therapy professor believes that the current health system is still not giving patients enough time to recover and underestimating what the human brain can do given the right conditions.

In a recent article for OT Practice Magazine, Guy McCormack, clinical professor and chair of the occupational therapy and occupational science department at the MU School of Health Professions, argues that health practitioners believe their clients need more time and motivation to reclaim lost functions, such as the use of an arm, hand or leg. With today’s therapies, it is possible for patients to regain more function than ever thought possible, McCormack said.

“Patients are able to regain function due to the principle of neuroplasticity, or the brain’s ability to change, especially when patients continue therapy long after their injuries,” McCormack said. “Therapists once believed the brain doesn’t develop new neurons; but, now they know neurons change their shape and create new branches to connect with other neurons, rewiring the brain following an injury or trauma.” Read More .

FTLD & PPA

Author: Alyssa Banotai

Rapidly developing molecular research has given clinicians more insight into frontotemporal lobar degeneration (FTLD), an umbrella term for a group of neurodegenerative conditions characterized by progressive degeneration of the frontal and anterior temporal lobes of the brain. Both behavioral variant frontotemporal dementia (bvFTD) and primary progressive aphasia (PPA) are clinical dementia syndromes caused by FTLD.

Speech-language pathologists are deeply involved in the treatment of this patient population. Patients with FTLD require tailored, comprehensive evaluations to account for the variability of the condition and its subtypes.

Treatment efficacy research in FTLD is still in its infancy. “Right now researchers are just trying to figure out what the molecules are that make up the cellular pathology,” said Sandra Weintraub, PhD, clinical core director of the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern University Feinberg School of Medicine in Chicago, IL. “In Alzheimer’s we know our targets are plaques and tangles, but we don’t know what our drug targets would be in the neuropathology that causes PPA and bvFTD. That’s a big part of the puzzle.”

PPA and bvFTD present with very different sets of symptoms. Patients with bvFTD generally present with behavioral and personality changes caused by damage to the areas of the prefrontal cortex linked to social cognition. Such changes can include lack of empathy or inappropriate social behavior.

PPA initially affects the language cortex but not necessarily memory. In patients with clinical symptoms, “episodic memory is intact in the early stages, before the pathology spreads to affect other brain regions,” Dr. Weintraub said. “They start having difficulty with word finding and make errors in speech.” Read More

The Future of Aphasia Research

Author: Alyssa Banotai

The Future of Aphasia Research - Emerging technology could improve treatment

Researchers hope two emerging technologies-fMRI and cortical stimulation-can one day improve our understanding of and subsequent treatment efficacy for patients with aphasia.

Leora Cherney, PhD, CCC-SLP, BC-NCD, director of the Center for Aphasia Research and Treatment at the Rehabilitation Institute of Chicago, and Steven Small, PhD, MD, a professor of neurology and psychology at the University of Chicago, are using functional magnetic resonance imaging (fMRI) to record changes in brain activity in patients with aphasia following speech and language therapy. The technology allows researchers to observe changes in blood flow and blood oxygenation levels that occur during activities such as communication. Dr. Cherney said the imaging technique “is an indirect way of measuring neuronal activity in the brain during a mental operation, including the production, formulation and understanding of language.”

Researchers are cautiously optimistic about fMRI, though existing studies generally have small subject numbers and use various imaging techniques, testing tasks and analyses. “We’re in our infancy in terms of being able to interpret what the changes in brain activity that we’re recording actually mean,” she told ADVANCE. “Many variables impact our interpretation of the fMRI,” including differences in lesion location and size, the tasks used in the scanner, and the language skills of the person with aphasia.

Still, she believes the technology holds the potential to determine which treatment approaches could best benefit individual patients based on the severity and type of their aphasia. “It can tell us which areas [of the brain] are active during a particular task and whether there is a change in activity as a result of therapy. At this point in time, it is a research tool and not a clinical tool in the area of aphasia,” she noted.

Observing brain activity during a language task is thought to be valuable since language is supported by a neuronal network that involves several areas of the brain. Researchers hope to use fMRI to observe the parts that are most essential to language production. “We want to be able to compare behavioral changes in language to those that occur neurophysiologically and determine if these are the result of the specific treatment,” she explained.

She and Dr. Small are collecting cognitive and language data on patients with stroke-induced aphasia before and after an intense course of speech and language therapy. They are using fMRI to scan patients during recovery to determine if there are relationships between behavioral and neurophysiological language-based changes that occur before and after the speech and language therapy.
Read More .

Author: Anne Bromley, U.Va. News Services

CHARLOTTESVILLE, Va., Feb. 20 (AScribe Newswire) — A middle-aged woman makes plans over the telephone to get together with a friend, even though she cannot talk after suffering a stroke. She is able to communicate using a hand-held device that speaks for her.

University of Virginia neurolinguist Filip Loncke has the only research site in the United States using the apparatus - a barcode reader called the B.A. Bar that was developed in Switzerland by the Federation Suisse des Teletheses and made available in that country in 2001.

Loncke, an assistant professor in the Communications Disorders program of the Curry School of Education, will discuss his work on Feb. 20 at the annual meeting of the American Association for the Advancement of Science in St. Louis.

From children with autism or Down’s syndrome to adults who have speech loss due to a stroke, more than two million Americans are not able to communicate easily or at all with words.

One of the advantages of the B.A. Bar (pronounced BA-bar) is its versatility - it has been used with people from the ages of 2 to 89 and has helped them learn or relearn how to speak and become more independent. Loncke and his research team are using it for several research and clinical applications.

The barcode reader provides auditory feedback when passed over the same kind of black-and-white strip used on grocery store products. In this case, the device is first used to program the barcodes with words or phrases; the barcodes can then be fixed to objects, pictures or places. The user scans the barcode with the device, and it says the word or phrase. Loncke’s research shows that it is more helpful than simple pictures.

The barcode reader is easy to use - an adult can learn it in one session, and a child with Down’s syndrome can become confident with it in six or seven, says Loncke, who has been working with the B.A. Bar for two years. He has partnered with the Woodrow Wilson Rehabilitation Center in Fishersville, Va. to work with some of its clients.

Loncke has found that after several sessions of training and practice, adults with aphasia, or speech loss, were able to recover and pronounce significantly more words from listening to a bar-coded list than from a written list. “It may be an indication that the added modality by the speaking barcode reader helped the participant in word retrieval,” he says.

Speech and literacy skills are important objectives in the education and rehabilitation of individuals who use augmentative communication, Loncke says. “For this reason, it is important to find out how the use of a speech-generating communication device affects the development (and the use) of internal speech.”

The device functions as “a great research tool” in furthering the understanding of how humans process language. Comparing use of the barcode reader by people with normal speech to those with impairments, he has found that it does not replace the brain’s normal formation of language before it is spoken, for example.

To view The complete article as posted in “Inside UVA Online”, please click here .

Another company who has numerous communication devices is Novitech .