let's talk: update on aphasia...
TRANSCRIPT
LET'S TALK: UPDATE ON APHASIA TREATMENT
DISCLOSURE
Leora R. Cherney, PhD Professor, Physical Medicine & Rehabilitation, Northwestern University;
Director, Center for Aphasia Research & Treatment, Rehabilitation Institute of
Chicago
• Receives salary from the Rehabilitation Institute of Chicago
• Is funded by grants from the NIH and NIDRR
• Receives an honorarium from AAPM&R for this presentation
LET'S TALK: UPDATE ON APHASIA TREATMENT
Current research in aphasia interventions has added to the understanding of how newer practices address recovery of communication abilities following stroke. This course will review the evidence for high-intensity speech language pathology interventions for aphasia, including oral reading for language in aphasia, scripts, and constraint programs. The current state of transcranial brain stimulation will also be discussed and new technologies to enhance communication abilities will be outlined.
Learning Objectives:
• Describe the evidence for the impact of medication and transcutaneous cortical stimulation on enhancing communication in adults with aphasia;
• Recommend the appropriate intensity, duration, and type of exercise in adults with new and/or chronic aphasia;
• Provide appropriate referrals for devices to enhance communication for patients with aphasia.
LET'S TALK: UPDATE ON APHASIA TREATMENT
Current research in aphasia interventions has added to the understanding of how newer practices address recovery of communication abilities following stroke. This course will review the evidence for high-intensity speech language pathology interventions for aphasia, including oral reading for language in aphasia, scripts, and constraint programs. The current state of transcranial brain stimulation will also be discussed and new technologies to enhance communication abilities will be outlined.
Learning Objectives:
• Describe the evidence for the impact of medication and transcutaneous cortical stimulation on enhancing communication in adults with aphasia;
• Discuss the appropriate intensity, duration, and type of exercise in adults with new and/or chronic aphasia;
• Provide appropriate referrals for devices to enhance communication for patients with aphasia.
PRINCIPLES OF EXPERIENCE-DEPENDENT
NEURAL PLASTICITY
Kleim & Jones, 2008
WHAT IS “TREATMENT INTENSITY”?
Warren, Fey, and Yoder (2007) and Baker (2012)
• Dose form i.e. the typical task or activity within which the teaching episodes are delivered
• Dose , i.e., # teaching episodes (unique combination of “active ingredients”) per session; number of therapeutic inputs or client acts per session (e.g. 100 trials)
• Session duration (e.g. 60 minutes)
• Session frequency (e.g. 3x per week)
• Total intervention duration (e.g. 12 weeks)
Cumulative Intervention Intensity (CII)
• dose x dose frequency x total intervention duration
• 100 trials X 3x a week X 12 weeks = 3600 productions of target
HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF A
CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN JOURNAL
OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.
HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF
A CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN
JOURNAL OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.
HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF A
CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN JOURNAL
OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.
HOW DO OUR APHASIA STUDIES MEASURE
UP TO THIS FORMULA?
Aphasia studies that directly compared conditions of higher
and lower intensity treatment for aphasia
Identified by 25 expanded terms used to search 15 electronic
data bases and specific journals related to aphasia
12 studies (N=225) • 1990-2006: 6 studies (Cherney et al., 2008)
• 2007-2011: 5 studies (Cherney et al., 2010, 2011)
• 2012-2014: 1 study (N=30) (Martins et al., 2013)
Dose reporting (Cherney, 2012) • 3/12 studies reported dose – so CII could only be calculated on 3/12 studies
• 8/12 studies reported: Session duration
• 9/12 studies also reported: Total # sessions
WHAT DOES THE LITERATURE TELL US
ABOUT APHASIA TREATMENT INTENSITY?
Considerations
• Acute/subacute vs Chronic aphasia
• Outcomes (WHO ICF levels)
Impairment
Activity/participation
ACUTE/SUBACUTE APHASIA
Results
Study Intensive Non-Intensive Equivocal
Impairment Bakheit et al.,
(2007) + Denes et al.,
(1996) + Martins et al.,
(2013) + Activity/
Participation
Martins et al.,
(2013) +
ACUTE APHASIA AND TREATMENT INTENSITY
Bakheit, A. M. O., Shaw, S., Barrett, L. et al. (2007). A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clinical Rehabilitation, 21, 885-894.
N=116; mean TPO = 34.2 days (intensive); 28.1 days (non-intensive)
Allocated to 5 hrs/wk and 2 hrs/wk for 12 weeks
Received 35.6 (16.4) hrs over 37.6 (14.9) sessions vs 19.3 (6.4) hrs over 19.3 (5.1 sessions)
No treatment effect of intensive therapy; contrasts with Denes et al. 1996
Amount of speech and language therapy received by intensive group was below the threshold required to significantly enhance language function; many patients were not able to tolerate more than 2 hrs/week of SLT in the first few weeks after stroke
SUBACUTE APHASIA AND TREATMENT INTENSITY MARTINS, I. P., LEAL, G., FONSECA, I., ET AL. (2013). A RANDOMIZED, RATER-BLINDED,
PARALLEL TRIAL OF INTENSIVE SPEECH THERAPY IN SUB-ACUTE POST-STROKE APHASIA: THE
SP-I-R-IT STUDY. INT J LANG COMMUN DISORD, 48, 421-431.
N=30; mean TPO = 7.67 weeks (intensive); 7.47 weeks (non-intensive)
Allocated to 2 hrs/day, 5 days/week for 10 weeks (Intensive) and 2 hrs/week for 50 weeks (Regular)
Primary outcome: Proportion of responders in each treatment group. Responder: Increase of at least 15 AQ points from baseline at 50 weeks
Trend for greater improvement in language and functional communication measures with Intensive compared to Regular treatment.
CHRONIC APHASIA
Study (N) Intensive Non-Intensive Equivocal
Impairment Basso & Caporali (2001)
(N=6) +
Harnish et al., (2008)
(N=1) +
Hinckley & Craig (1998)
(N=10) +
Pulvermuller et al., (2001)
(N=17) +
Ramsberger & Marie (2007)
(N=4) +
Raymer et al. (2006)
(N=5) +
Sage et al. (2011)
(N=8) +
Activity/
Participation
Hinckley & Carr (2005)
(N=13) +
Lee et al. (2009)
(N=17) +
COMMENTS: OPTIMUM DOSING?
Complex inter-relationship between treatment intensity and improvement
Consider, for e.g.: • Participant characteristics (WHO)
Severity of aphasia Time post stroke
• Treatment characteristics Treatment targets (WHAT)
Specificity Complexity
Type of Treatment (HOW) Error-free vs error-less Part vs whole
• Treatment scheduling (WHEN) Session length Treatment duration Timing of treatment (time of day)
Perhaps there is a threshold that must be reached in order to make long-lasting improvements
BEST (POSSIBLE/AVAILABLE) CURRENT SCIENTIFIC
EVIDENCE – CHRONIC APHASIA
Allen et al. (2012). TSR;19:523-535
• Search yielded 744 studies; 21 met inclusion criteria (RCT)
• 15 distinct interventions that fell into 5 treatment categories:
Constraint induced aphasia therapy
Language and communication therapies
Technological interventions
Pharmacotherapies
Brain stimulation techniques
A PARADIGM FOR LANGUAGE ACTION THERAPY
Difrancesco S, Pulvermuller F, Mohr
B. Intensive language-action therapy
(ILAT): The methods. (2012)
Aphasiology, 26, 1317-1351.
PRINCIPLES OF CILT
Forced verbal language use
• Verbalization required; Compensatory strategies prohibited
Intensive treatment schedule • 3 hrs/day 5 days/week 2 weeks • Massed practice
Shaping verbal responses • Begin with words or short phrases • Move to longer and more complex utterances • Barrier games • Go Fish–like activity: pictures selected for individual participants;
response components predetermined
Initial publication: Pulvermuller et al. (2001) Constraint-Induced Therapy of chronic aphasia after stroke. Stroke, 32, 1621-1626.
CILT TREATMENT (Maher et al., 2006)
Materials: Pairs of cards Level 1: Single words
• Request: Speaker communicates: book • Response: Receiver communicates: yes + book; no + book
Level 2: Carrier phrase + noun • Request: Speaker communicates: Bill, do you have a book ? • Response: Receiver communicates: Yes, Patrick, I have a book; No,
Patrick, I do not have a book
Level 3: Carrier phrase + adjective + noun • Request: Speaker communicates: Bill, do you have a red book ? • Response: Receiver communicates: Yes, Patrick, I have a red book; No,
Patrick, I do not have a red book
Level 4: Carrier phrase + # + adjective + noun • Request: Speaker communicates: Bill, do you have three red books ? • Response: Receiver communicates: Yes, Patrick, I have three red books;
No, Patrick, I do not have three red books
CONSTRAINT INDUCED LANGUAGE
THERAPY (CILT)
Pulvermuller et al., 2001
• RCT
• CILT: communicate only verbally; all compensatory
strategies suppressed; average of 31.5 hrs of Rx over
2 weeks
• Traditional therapy: average of 33.9 hours over 3-5
weeks
• CILT group improved significantly on AAT and a
Communicative Activity Log (CAL)
• Are improvements due to type of Rx or intensity of Rx?
Overall language profile scores calculated as the average of results from 4 clinical tests
revealed significant improvement in the CI aphasia therapy group but not in the control group
receiving conventional aphasia therapy.
Pulvermüller F et al. Stroke. 2001;32:1621-1626
Copyright © American Heart Association, Inc. All rights reserved.
CONSTRAINT INDUCED LANGUAGE THERAPY (CILT)
MODIFICATIONS/INDIVIDUALIZATION
Topics relevant to particular patient
• Easy to get images from google images
Level relevant to particular patient
• Flexible so not too hard or too easy
Language structures/Speech acts addressed:
• Requests / Commands / Statements
• Single words / noun phrase / S-V-O sentence
• Verbs (past/present)
Production and/or Comprehension task
Target: phonology/semantics/ syntax
Play videos
WHAT DOES THE LITERATURE TELL US
ABOUT CILT?
Cherney, L. R., Patterson, J. P., Raymer, A. et al. (2008). Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282-1299.
Update, 2010.
http://www.asha.org/uploadedFiles/EBSR-Updated-CILT.pdf
CILT SUMMARY
18 studies with 202 participants
Language impairment measures
Acute aphasia: One study; improvement shown
Chronic aphasia: 11 exploratory studies with mixed results
2 efficacy studies reported significant change
Most participants had nonfluent aphasia Communication activity/participation measures Acute aphasia: One study; change on treatment task
Chronic aphasia: Results generally favor CILT
Varying tasks and response targets
Evolution of constraints: relatives as clinicians; dosage;
pharmacotherapy; RH activation; syntax module; activities • Maintenance of CILT effects: Equivocal evidence
ORAL READING FOR LANGUAGE IN APHASIA (ORLATM)
Sentences and paragraphs repeatedly read aloud, first in
unison with the clinician and then independently
Key Element: • Theoretical basis
• Oral reading is systematically applied
• Focuses on connected discourse
• Permits modeling of more natural speech
• Allows practice on a variety of grammatical structures
• Graded levels based on stimuli length and reading level
• Consistent with Principles of Learning Theory Active participation by the learner
Repetitive practice in the overlearning of skills
Use of meaningful materials that are graded in difficulty
ORLATM PARTICIPANT
Play videos
ORLATM – SCREEN SHOTS
ORLA: ASSESSING TREATMENT INTENSITY
(FROM CENTER FOR APHASIA RESEARCH AND TREATMENT,
REHABILITATION INSTITUTE OF CHICAGO; NIDRR - H133G040269)
Randomized Single-Blind Intent-to-Treat Study of Chronic Nonfluent Aphasia • Comparing high-intensity (10 hours per week) and
low-intensity (4 hours per week) aphasia treatment Using as a treatment platform a computer version of Oral
Reading for Language in Aphasia (C-ORLA)
A Matched No-Treatment Control Group (historical) • Comparing high-intensity (10 hours per week) and
low-intensity (4 hours per week) C-ORLA to no-treatment
STUDY DESIGN
Pre-Treatment Assessment
Randomization
Post-treatment Assessment
High Intensity
Language Tx
No Tx Matched
Controls
Low Intensity
Language Tx
Interim Testing
Non-fluent
aphasia
4 hrs/week 10 hrs/wk Control
Group
# Subjects 12 10 25
Males:
Females
9:3 5:5 16:9
Age 55.57 (15.06)
31.35-77.98
56.54 (13.97)
25.83-74.50
58.2 (12.0)
35.18-79.64
Months
post onset
50.70 (45.84)
7.3-159.8
37.84 (26.26)
7.6-77.3
54.0 (59.30)
12.2-253
Baseline
WAB AQ
48.76 (22.18)
13.7-77.1
49.59 (19.37)
28.0-78.9
53.74 (25.34)
9.7-81.4
Mean Change in WAB AQ Scores from Pre- to Post-Treatment
-1
0
1
2
3
4
5
6
7
8
Me
an
Ch
an
ge
in
WA
B A
Q
Series1 5.21 -0.36 3.92 6.76
C-ORLA - All Subjects No Tx Controls 4 hour 10 hour
Mean Change in WAB AQ from PreTreatment
0
1
2
3
4
5
6
7
8
Mean
ch
an
ge in
WA
B A
Q
Series1 3.92 1.66 6.76
4 Hour Group: Post Tx 10 Hour Group: Interim 10 Hour Group: Post Tx
INDIVIDUAL SUBJECT DATA
C-ORLA 4-Hour Treatment Group
Pre- and Post-Treatment WAB Score
0
10
20
30
40
50
60
70
80
90
Subjects
WA
B A
Q S
co
re
Pre-Tx
Post Tx
Pre-Tx 13.7 19.2 26.6 36.3 39.9 43.1 53.8 61 67.4 72.9 74.1 77.1
Post Tx 10.3 21.4 29.3 34 43 58.6 65.3 57.6 77.4 81.7 73.4 80.1
1 2 3 4 5 6 7 8 9 10 11 12
C-ORLA 10-hour Treatment Group
Pre- , Interim and Post-Treatment WAB Scores
0
10
20
30
40
50
60
70
80
90
Subjects
WA
B A
Q S
co
re
PreTx
Interim
Post Tx
PreTx 28 29.8 31.8 34.1 37.1 56 62.7 68.1 69.4 78.9
Interim 30.4 35.2 39.5 27.3 37.2 53.7 72.2 66.8 72.3 77.9
Post Tx 33.2 46.8 54 34.4 45.6 62.4 69.9 68.1 71.6 77.5
1 2 3 4 5 6 7 8 9 10
CONCLUSIONS – IS MORE BETTER?
C-ORLA may be an efficacious treatment for people with chronic nonfluent aphasia
Over a 6-week period, there was a trend for greater language improvement with increased intensity and amount of therapy
After 24 treatment sessions, there was a trend towards greater improvement when sessions scheduled less intensively
There may be a critical amount and intensity of treatment needed for maximum improvement; depending on the nature of the treatment (as well as subject characteristics, outcome measures) different intensities of treatment may be preferable at different times during the learning process (acquisition vs retention and transfer)
Adequate power ?
APHASIA SCRIPTS: TRAINING SEQUENCE
1. Listening/reading whole conversation
2. Single sentence practice
• Self-monitoring
• Individual word practice
3. Conversation practice
• Options to remove cues (face, voice, written words)
QUESTION 1:
Does amount of treatment correlate
with amount of improvement on
conversational script measures
• Content (number of script related words)
• Rate (script related words per minute)
RESEARCH PROTOCOL
Three personalized scripts are developed for each subject
Each script is practiced for three weeks (total of 9 weeks of treatment)
Scripts are practiced daily at home for at least 30 minutes on a loaned laptop
Once-weekly sessions with SLP to check status and ensure compliance
Script training facilitated by state of the art software program
PARTICIPANTS
(8 MALES; 9 FEMALES)
Age Time post
stroke
(months)
WAB AQ
Mean 53.3 65.8 65.1
Std
Deviation
12.7 67 15.3
Range 31-70 10.6 –
272.7
30.5 – 85.3
PARTICIPANT TREATMENT TIME (N=16; REMOVAL OF OUTLIER WITH 151.85 TOTAL HRS; 16.8 HRS/WK
Total Hours
over 9 weeks
Mean hours per
week
Mean 40.32 4.48
Std. Deviation 15.11 1.68
Range
17.40 - 68.61 1.93 - 7.62
CORRELATIONS BETWEEN TREATMENT HOURS
AND OUTCOMES (% CHANGE)
Content (number of script related words)
• Mean change = 45.72% (SD=57.59)
• r=.67, p<.01
Rate (script related words per minute)
• Mean change = 137.48% (SD=109.53)
• r=.53, p<.05
THE INTENSIVE COMPREHENSIVE APHASIA
PROGRAM (ICAP): DEFINITION
High Intensity
• ≥ 3 hrs/day
• 4-5 days/wk
• ≥ 2 weeks
Combination of
approaches
• Individual
• Group
• Technology
Targets all areas of ICF
• Impairment
• Activity
• Participation
Patient & Family Education
Cohort of participants
• Starts and ends at same
time
Cherney et al., 2011; Rose, Cherney, & Worrall, 2013
9/2/11
2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation
LIVING WITH APHASIA: FRAMEWORK FOR
OUTCOME MEASUREMENT (A-FROM)
INTERNATIONAL SURVEY RESULTS (ROSE,
CHERNEY & WORRAL, 2013)
Number and distribution of hours
Staffing
Family Involvement
Admission Criteria
Factors that contribute to ICAP success
INTERNATIONAL SURVEY RESULTS - NUMBERS
Years in
Operation
Times
offered per
year
Number of
PWA per
year
Number of
hours of
service
Hours per
day
Avg 4.6
Range (1-20)
Avg 3.13
Range (1-12)
Avg 17.3
Range (3-60)
Avg 101
Range (48-
150)
Avg 4.75
Range (3-7)
12 ICAPs reporting:
INTERNATIONAL SURVEY RESULTS - NUMBERS
Years in
Operation
Times
offered per
year
Number of
people per
year
Number of
hours of
service
Hours per
day
Avg 4.6
Range (1-20)
Avg 3.13
Range (1-12)
Avg 17.3
Range (3-60)
Avg 101
Range (48-
150)
Avg 4.75
Range (3-7)
RIC ICAP
6 YEARS 2 TIMES 20 120 HOURS 6 HRS/DAY
12 ICAPs reporting:
RIC’S INTENSIVE COMPREHENSIVE
APHASIA PROGRAM
What is a day like?
• 2 hours of Individual Treatment
• 1 hour CILT
• 1 hour Reading/Writing session
• 1 hour computer session
• 1 hour conversation group
RIC Intensive Aphasia Program Week 2 April 29 – May 3
Period Monday Tuesday Wednesday Thursday Friday
9.00
Constraint
Therapy
(Room 22)
Constraint
Therapy
Constraint
Therapy
Constraint
Therapy
Constraint
Therapy
10.00
Individual
Therapy
Individual
Therapy
Individual
Therapy
Individual
Therapy
Individual
Therapy
11.00
Reading /
Writing Group
Reading /
Writing Group
Reading /
Writing Group
Reading /
Writing Group
Reading /
Writing Group
12.00
Lunch
Lunch
Lunch
Lunch
Lunch
1.00
Computers
Computers
Computers
Computers
Computers
2.00
Individual
Therapy
Individual
Therapy
Individual
Therapy
Individual
Therapy
Individual
Therapy
3.00
Conversation
Group
(computer lab)
Conversation
Group
Conversation
Group
Conversation
Group
Conversation
Group
4.00
Music Therapy
Rm. 850
5:00 p.m.
Dinner
(optional)
Music Therapy
Rm. 850
FIRST TIME PARTICIPANTS
PRELIMINARY PAIRED T-TEST: LANGUAGE MEASURES
WAB AQ (100)
WAB LQ (100)
WAB CQ (100)
BNT (60)
Mean Pre (SD)
Mean Post (SD)
49 (24)
56 (23)
52 (19)
60 (18)
60 (18)
66 (18)
17 (20)
21 (21)
Difference +7 +8 +6 +4
p value <.001* <.001* <.001* <.001*
N= 63 60 38 58
Babbitt, Worrall &
Cherney (2014)
PRELIMINARY PAIRED T-TEST:
PARTICIPATION MEASURES
REPORTEDOUTCOMES CETI
PWA (100)
CETI
Caregiver
ASHA-QCL (80)
CCRSA (40)
Mean Pre (SD)
Mean Post (SD)
55 (18)
64 (18)
47 (17)
58 (16)
58 (11)
62 (11)
27 (6)
30 (6)
Difference +9 +11 +4 +3
p value <.001* <.001* <.001* <.001*
N= 61 60 62 59
CETI CG difference score > 11.4
Lomas et al 1989
Persad, Wozniak & Kostopoulos. 2013
UMAP – 54 first-time PWA from 1999 – 2010
• Majority of PWA (42/54) showed clinically significant improvement
on objective language impairment measures
InterACT – 71 first-time PWA from 2002 – 2012
• Majority of PWA (45/71) showed clinically significant improvement
on objective language impairment measures
• About 50% PWA showed clinically significant improvement in
functional communication
• Fewer than 5% did not make a clinically significant change on any
measure (WAB, CADL, CETI)
Age, gender and TPO were not predictive of therapy outcome.
SELECTED REFERENCES - CILT
Cherney, L.R., Patterson, J., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals with Stroke-Induced Aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282-1299.
Cherney, L.R., Patterson, J., Raymer, A., Frymark, T., & Schooling, T. (2010). Updated Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia. Available at: http://www.asha.org/uploadedFiles/EBSR-Updated-CILT.pdf
Difrancesco S, Pulvermuller F, Mohr B. Intensive language-action therapy (ILAT): The methods. (2012) Aphasiology, 26, 1317-1351.
Faroqi-Shah, Y. & Virion, C. R. (2009). Constraint-induced language therapy for agrammatism: Role of grammaticality constraints. Aphasiology, 23, 977 – 988.
Goral, M. & Kempler, D. (2009). Training verb production in communicative context: Evidence from a person with chronic non-fluent Aphasia. Aphasiology. 23(12), 1383–1397.
Kurland, J., Pulvermuller, F., Silva, N., Burke, K., & Andrianopoulos, M. (2012). Constrained vs unconstrained intensive language therapy in two individuals with chronic, moderate-to-severe aphasia and apraxia of speech: Behavioral and fMRI outcomes. American Journal of Speech-Language Pathology, 21, S65-S87.
Kirmess, M., & Maher, L. (2010). Constraint induced language therapy in early aphasia rehabilitation. Aphasiology, 24, 725–736.
Maher, L.M., Kendall, D., Swearengin, J.A., Rodriguez, A., Leon, S.A., Pingel, K., Holland, A., & Rothi, L.J.G. (2006). A pilot study of use-dependent learning in the context of constraint induced language therapy. Journal of the International Neuropsychological Society, 12, 843-852.
Meinzer, M., Djundja, D., Barthel, G., Elbert, T., Rockstroh, B. (2005). Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36, 1462-1466.
Meinzer, M., Elbert, T., Wienbruch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20. Retrieved from: www.biomedcentral.com/1741-7007/2/20.
Meinzer, M., Rodriguez, A. D., Gonzalez Rothi, L. J.. (2012). First decade of research on constrained-induced treatment approaches for aphasia rehabilitation. Arch Phys Med Rehabil, 93(1 Suppl 1), S35-45.
Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, Br., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621-1626.
Pulvermuller, F., Hauk, O., Zohsel, K., Neininger, B., & Mohr, B. (2005). Therapy-related reorganization of language in both hemispheres of patients with chronic aphasia. NeuroImage, 28, 481-489.
REFERENCES - ORLA
Cherney, L. R. (2010). Oral Reading for Language in Aphasia (ORLA): Impact of aphasia severity on cross-modal outcomes in chronic nonfluent aphasia. Seminars in Speech-Language Pathology, 31, 42-51.
Cherney, L. R. (2010). Oral Reading for Language in Aphasia (ORLA): Evaluating the Efficacy of Computer-Delivered Therapy in Chronic Nonfluent Aphasia. Topics in Stroke Rehabilitation, 17(6), 423-431.
Cherney, L. R., Kaye, R. C., & Hitch, R.S . (2011). The best of both worlds: Combining synchronous and asynchronous telepractice in the treatment of aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 21(3), 83-93.
Cherney, L., Merbitz, C. and Grip, J. (1986). Efficacy of oral reading in aphasia treatment outcome. Rehabilitation Literature, 112-119.
Cherney, L. R. (1995). Efficacy of oral reading in the treatment of two patients with chronic Broca's aphasia. Topics in Stroke Rehabilitation, 2(1), 57-67.
Cherney, L. R., Babbitt, E. M., & Oldani, J. (2004). Cross-Modal Improvements During Choral Reading: Case Studies. Presented at the Clinical Aphasiology Conference, Park City, Utah, May, 2004.
Cherney, L. R. (2004). Aphasia, Alexia, and Oral Reading. Topics in Stroke Rehabilitation, 11(1), 22-36
REFERENCES - SCRIPTING
Bilda, K. (2011). Video-based conversational script training for aphasia: A therapy study. Aphasiology, 25, 191 – 201.
Cherney, L. R. & Halper, A. S. (2008). Novel Technology for Treating Individuals with Aphasia and Concomitant Cognitive Deficits. Topics in Stroke Rehabilitation, 15(6), 542-554.
Cherney, L. R., Halper, A. S., Holland, A. L., & Cole, R. (2008). Computerized script training for aphasia: preliminary results. American Journal of Speech-Language Pathology, 17, 19-34.
Cherney, L. R., Halper, A. S., Holland, A. L., Lee, J. B., Babbitt, E., & Cole, R. (2007). Improving conversational script production in aphasia with virtual therapist computer treatment software. Brain and Language, 103, 246-247.
Cherney, L. R., Halper, A. S., & Kaye, R. C. (2011). Computer-based script training for aphasia: Emerging themes from post-treatment interviews. Journal of Communication Disorders, 44, 493–501.
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