using neuroscience to understand aphasia recovery ucl institute of neurology shedding some light...

Using Neuroscience to understand aphasia

recovery

UCL INSTITUTE OF NEUROLOGY

Shedding some light into the darkness!


Who are we?Louise Lim Research Associate and Speech & Language Therapist

Johanna Rae Research Assistant (Bilingual) and Speech & Language Therapist

From:University College London, Institute of Neurology, Wellcome Trust Centre for Neuroimaging


The patient-facing team

Prof Cathy Price

Dr Alex Leff

Louise Lim

Zula Haigh

Rachel Browne

Johanna Rae

PLORAS


Aphasia

An acquired language disorder following brain injury.

• Affects a third of stroke survivors

• Can involve understanding language, speaking, reading and writing

• One of the most feared outcomes after stroke (Soloman, Glick, Russo, Lee and Schulman, 1994)


Impact of Aphasia on Carers

Communication difficulties due to aphasia following stroke are particularly difficult for caregivers…

isolation

role-changeidentity

stressdepression

helplessness


From the literature Most studies conclude that:

• Caregivers of aphasic stroke patients are more stressed, with symptoms of depression, loneliness and other emotional problems than caregivers of non-aphasic stroke patients.

• Their (carers of people with aphasia’s) overall adjustment to the stroke is poorer and they experience greater role changes.

• They have more marital difficulties with a greater number of negative attitudes toward their spouse.

(Draper at al. 2007)


‘Not-knowing’

Recovery from aphasia is hugely variable (Hillis and Heidler, 2002)

Speech can be regained within the first few days, weeks or months after stroke or may take several years

…how can carers and patients prepare for the future?


Impact of an unknown futureThe recovery road could be…..

Carers and patients want to be prepared for the right journey

or


In the words of patients

“People can’t move forward until they know what’s happened to them and what the future might be”

“If you don’t know what’s happened and what the possible outcomes are it’s not possible to move forward”

With thanks to the stroke survivor presentations at the Stroke Associations UK Stroke Forum 2012


Needs of stroke survivors and carers

• A clear understanding of what has happened

• A long term plan

• Range of possible outcomes: short and long-term

To take ownership of their recovery


The role of the Health Professional:

The ‘tour guide’ for the journey

• What to expect – recovery outcome• Realistic short and long term goals• Support and advice

This way please…

???


What guides Health Professionals?

• Initial severity?• Lesion size?• University?• Experience?• Research literature?• Intuition?

How confident are we that we can provide well-evidenced answers to carer’s questions about recovery?


The tightrope for Health Professionals

False hope

High expectations

Despondency

Lack of motivation for therapy

Realistic goals & appropriate support

Depression


Accurately predicting recovery: problem to date

Lack of understanding of how lesion site influences language outcome & recovery…

?

Years post stroke

Speaking ability


therefore…

Predicting the recovery journey for each patient is difficult

A bit like predicting the weather in Britain based on the day before?!


Ingredients requiredTo understand the relationship between lesion

location and language recovery we need:

• Between-patient cross-sectional comparisons for large numbers of patients

• Accurate ways of defining & comparing the lesion

• Additional within-patient longitudinal comparisons to check accuracy of predictions


PLORAS project

Predicting Language Outcome and Recovery

After Stroke

Aim = Create a clinical tool for patients, carers and clinicians

To provide individualised predictions about recovery from aphasia after stroke, based on patient’s MRI brain image

Realistic goal-setting in therapyPlan for a return to valued activitiesAppropriate level and timing of support


Between-patient cross-sectional comparisons for large numbers of patients

Over 500 stroke patients (and growing daily!) from

• Hospital

UCLH & NHNN

• Community

stroke groups, adverts, conferences etc


Procedure

1.Comprehensive Aphasia Test (CAT)• Cognitive screen• Language battery• Widely used in clinical practice

2. MRI scan• Structural scan – 15 minutes


Accurate ways of defining & comparing the lesion

High resolution 3D lesion images and advanced lesion identification software

Voxel based analysis = improved accuracy


Meaningful interpretation of language scores

Use composite language scores e.g.

‘speech production’ score considers:

word repetition + sentence repetition + picture naming + picture description

so that visual or auditory problems alone cannot account for impairment


Combine lesion information with language scores

For hundreds of patients…

Establish the relationship between:

• Exact lesion location • Composite language score• Time post stroke


Understanding the lesion - behaviour relationship enables predictions for patients


NB ‘recovery’ defined as WNL scores on Comprehensive Aphasia Test

Examples of Findings


Key findings• Accurate relationship between lesion site and

recovery profile – tested at 98% accuracy

• Patients with speech output difficulties persisting beyond 5 years had damage that severed both anterior and posterior segments of the superior longitudinal fasciculus


Key findings

Speech score

A

Aphasic range

A&P

Non-aphasic range

P

PLORAS


Future work

Continually expanding patient numbers- Coming to a hospital near you (hopefully!) via the

Stroke Research Network

Adjusting predictions for clinical scans: CT/ MRI

Understanding influence of other factors- Age, motivation, amount of therapy

Functional MRI scanning with recovered patients

- To see use of alternative regions to damaged


Discussion 1: Your experiences

Please help us by sharing your experiences of…

• What patients and carers have asked you about recovery

• What patients and carers have told you about recovery

• What kinds of answers you/others have given

• Difficulties associated with answering questions about recovery


Discussion 2 : Your opinion

What are the implications (positive and negative) for:

• Patients• Carers• Health Professionals

Of the availability of prediction information?

What kind of information would you like to be able to give patients and carers?

How might it influence your practice?


Discussion 3: Your advice

Giving patients recovery predictions…

• Who? e.g. therapist, doctor, support worker

• When? e.g. first week, on discharge, at home

• How? e.g. face to face, self-access

• Where? e.g. whilst in hospital, in community

• As routine? Only if asked? In worst cases?


Taking PartWe are always recruiting patients for our research.

Inclusion criteria:• Have had a stroke.• Are able to have an MRI brain scan (we can tell you).• Are happy to have their language assessed.• Can travel to London (private transport negotiable).

We are interested in people who speak English only AND people who speak more than one language.

PLORAS


Contact Details

• Location: 12 Queen Square, London, WC1N 3BG

• E-mail: [email protected]

• Telephone: 020 7813 1538

• Add us as a friend on Facebook: Stroke Study

• ‘Like’ our Facebook page: Aphasia Research at Wellcome Trust Centre for Neuro-imaging, UCL

• Video: http://www.wellcome.ac.uk/News/2009/Features/WTX057690.htm

• http://www.youtube.com/watch?v=Wn08mkGbGnQ

http://www.facebook.com/stroke.study?ref=tn_tnmn

http://www.facebook.com/stroke.study?ref=tn_tnmn

http://www.facebook.com/pages/Aphasia-Research-at-Wellcome-Trust-Centre-for-Neuro-imaging-UCL/209568425804367?ref=hl




Photograph credits

From Flickr – creative commons.

• Geodesic for ‘Road’• Rawmusic for motorway image• Girlguides of Canada for ‘Guides Book 1’• The Other Martin Taylor for ‘Tightrope Walker’• Slawek Puklo for storm image• Rhys Asplundh for ‘Sun & Clouds’• Doug 888 for ‘Richmond Snow’


References• Brady, M., Kelly, H., Godwin, J., Enderby, P. 2012 Speech and language

therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 5.

• Draper, B., Bowring, G. Thompson, C., Van Heyst, J. Conroy, P., Thompson, J. Stress in caregivers of aphasic stroke patients: a randomised control trial. Clinical Rehabilitation, 2007 Feb; 21(2): 122-30

• Hillis, A. and Heidler, J. 2002. Mechanisms of early aphasia recovery. Aphasiology, 16(9), 885-895

• Price, C., Seghier, M., and Leff, A. 2010. Predicting language outcome and recovery after stroke: the PLORAS system. Nature Reviews Neurology 6, 202-210 .

• Seghier, M., Lee, H., Schofield, T., Ellis, C. and Price, C. 2008. Inter-subject variability in the use of two different neuronal networks for reading aloud familiar words. Neuroimage. 42(3-3): 1226–1236.

• Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. 1994.Patient preferences for stroke outcomes, Stroke. Sep;25(9):1721-5.

• Swinburn, K., Porter, G. and Howard, D. 2004. Comprehensive Aphasia Test. Hove: Psychology Press.


EXTRA SLIDES

Slides from here on for use if time remaining after

discussion…


PLORAS Aim 2

To further the theoretical understanding of aphasia recovery, so that the effect of therapy

can be accurately tested

PLORAS


Efficacy of impairment-based therapy

• Currently there are problems proving efficacy of therapy.

• Cochrane review (2012): ‒ “…insufficient evidence to indicate the best approach to

delivering speech and language therapy”. ‒ None of the 39 studies in Cochrane review accounted for lesion

site.

PLORAS


Lesion information

We believe lesion site is critical in determining recovery and response to impairment-based therapy.

• To understand who will and will not respond to an intervention approach we first need to know:− Which brain regions are damaged?− How does damage affect language?− How does intervention influence the preserved

pathways?

PLORAS


Future implications

• Knowledge of typical recovery trajectory• To provide a baseline against which to compare therapy• Does a given therapy speed up this typical recovery?

after intervention

predicted by lesion sp

eech

sco

re

Time post stroke

PLORAS


Recovery pathways

Example of how the effect of damage to one pathway depends on the integrity of other pathways.

Damage to Recovery pathway

White pathway Red pathway

Red pathway White pathway

Red and white pathways

?

Seghier et al. (2008)

PLORAS

using neuroscience to understand aphasia recovery ucl institute of neurology shedding some light...

Documents

recovery slide

language recovery

ability slide

minutes slide

neuroimaging slide

stroke soloman

stroke aim

timing of support slide