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Efficacy of intensive speech therapy in aphasic patients due to vascular causes
Aphasia is a language impairment resulting from brain damage, and which can affect speech, hearing comprehension, reading and writing.
Cardiovascular diseases in general and Cerebrovascular Accidents (CVA) in particular, are the first cause of death in developed countries. In the USA, there are 795.000 new CVA cases per year, that is, one every 4 seconds (American Heart Association, 2010).
The most frequent cause of aphasia in the adult population is cerebrovascular diseases, affecting about 1/3 of those who suffer CVAs (Pedersen et al., 1995), although cranioencephalic trauma, infectious diseases of the central nervous system and some brain tumours may also provoke it. Language is lateralized preferably to the left hemisphere of the brain in the majority of right-handed men, and the aphasia results mostly from vascular lesions on that side of the brain. The recovery curve of aphasia of vascular origin has been best characterized (Mazzoni et al., 1992).
Following the initial injury, there is almost always a degree of spontaneous recovery during the first three months, particularly in the first three weeks (Hartman, 1981). Improvement tends to stabilize between the third and the sixth month and, generally speaking, there are no significant changes in the clinical profile after the first year of the disease (Basso, 1992; Sarno and Levita, 1979). In some cases, there is even clinical deterioration (Hanson, 1989; Fonseca et al., 1993).
In psychosocial terms, the presence of aphasia plays a determinant role in functionality (Paolucci et al., 1988), in emotional status (Starkstein and Robinson, 1988; Ferro and Madureira, 2002), in the quality of life (Melo et al., 1988; Sarno, 1997), and in terms of the chances of returning to work (Fonseca et al., 1993).
Biological variables seem to be of particular importance in the prognosis, namely location and extension of the lesion, etiology, and the initial gravity of the aphasic profile (Basso, 1992).
According to several authors, (Poeck et al., 1989; Basso, 1992; Mazzoni, 1995), speech therapy influences recovery positively. Acknowledgement of its efficacy has been confirmed over the last years in functional neuroimaging studies (Small et al., 1998; Musso et al., 1999; Léger et al., 2002; Peck et al., 2004).
In 2003, Bhogal and collaborators identified all controlled studies (between 1975 and 2002) through a systematic review of aphasia rehabilitation, selecting just 10 for analysis. They concluded that the positive effect of the therapy occurred above all when it was administered in intensive and brief form.
Classic therapy normally involves two to three weekly sessions, lasting one hour, for an average period of six months.
Since 2005, the Laboratory for Language Studies, in collaboration with the Alcoitão Rehabilitation Medicine Centre, has been carrying out a parallel (with two branches) multicentric clinical trial, controlled and randomized, on the efficacy of intensive speech therapy in patients affected by aphasia of vascular origin (SPIRIT).
The distribution of patients by the two therapeutic branches is determined by the severity of the aphasia. In both groups, patients undergo speech therapy for 100 hours, of which two hours per day, five days a week and for a period of 10 weeks, are in an intensive therapy group, and two 1-hour weekly sessions for 50 weeks in the control group.
Patients are evaluated four times: in the beginning (T0); at 10 weeks (T!), corresponding to the end of the treatment period in the intensive therapy group and to an intermediate evaluation in the group of conventional therapy; at 50 weeks (T”), corresponding to the final stage of control group therapy and to a late evaluation of the intensive group ,and at 62 weeks (T3), which corresponds to a follow-up evaluation of both groups.
Preliminary results seem to point to a more marked and faster improvement of the group subject to intensive speech therapy, which will need to be confirmed with the admission of more subjects in the study.
Since the beginning, 945 patients have been evaluated at the two study centres, but only 2.9% (27 patients) have been included in the study, because they were the only ones who met the inclusion criteria
Of those excluded, 70% were left out due to a single criterion, and 30% due to several.
Of the 655 who were excluded due to exclusively one factor, 43,2% were for diagnostic reasons, 10% because their had non-eligible etiologies, about 8% because they presented a long evolution time and about 28% due to multiple reasons
The extremely reduced number of patients admitted on this study confirms the difficulty in carrying out controlled studies in this field of knowledge, given the presence of so many variables which can influence the course of recovery. Nonetheless, only with methodologically correct studies will we be able to draw truly credible conclusions which will actually help us understand the best way to assist this type of patients who have difficulties in one of the noblest capacities of human beings: communicate
José Fonseca
Laboratory for Language Studies
jfonseca@fm.ul.pt
_______________
Bibliography:
Basso, A. (1992). Prognostic factors in aphasia. Aphasiology, 6 (4), 337-348.
Bhogal, S.K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34 (4), 98-993.
Ferro, J.M. & Madureira, S. (2002). Recovery from cognitive and behavioral deficits. In J. Bogousslavsky (Eds), Long term effects of stroke, (p. 149-181). Marcel Dekker, Inc., New York
Fonseca, J.M.; Farrajota, L., Leal, G. & Castro Caldas, A. (1993). Aphasia tem years later. Journal of Clinical and Experimental Neuropsychology,15 (3), 398.
Hartman, J. (1981). Measurement of early spontaneous recovery from aphasia with stroke. Ann Neurol, 9, 89-91.
Peck, K.K.; Moore, A.B.; Crosson, B.A. Gaiefsky, M.; Gopinath, K.S.; White, K. & Briggs, R.W. (2004). Functional Magnetic Resonance imaging before and after aphasia therapy: shifts in hemodynamic time to peak during an overt language task. Stroke, 554-559.
Pedersen, P.M.; Jorgensen, H.S.; Nakayama, H.; Raaschou, H.O. & Olsen, T.S. (1995). Aphasia in acute stroke: Incidence, determinants and recovery. Annals of Neurology, 38, 659-666.
Cardiovascular diseases in general and Cerebrovascular Accidents (CVA) in particular, are the first cause of death in developed countries. In the USA, there are 795.000 new CVA cases per year, that is, one every 4 seconds (American Heart Association, 2010).
The most frequent cause of aphasia in the adult population is cerebrovascular diseases, affecting about 1/3 of those who suffer CVAs (Pedersen et al., 1995), although cranioencephalic trauma, infectious diseases of the central nervous system and some brain tumours may also provoke it. Language is lateralized preferably to the left hemisphere of the brain in the majority of right-handed men, and the aphasia results mostly from vascular lesions on that side of the brain. The recovery curve of aphasia of vascular origin has been best characterized (Mazzoni et al., 1992).
Following the initial injury, there is almost always a degree of spontaneous recovery during the first three months, particularly in the first three weeks (Hartman, 1981). Improvement tends to stabilize between the third and the sixth month and, generally speaking, there are no significant changes in the clinical profile after the first year of the disease (Basso, 1992; Sarno and Levita, 1979). In some cases, there is even clinical deterioration (Hanson, 1989; Fonseca et al., 1993).
In psychosocial terms, the presence of aphasia plays a determinant role in functionality (Paolucci et al., 1988), in emotional status (Starkstein and Robinson, 1988; Ferro and Madureira, 2002), in the quality of life (Melo et al., 1988; Sarno, 1997), and in terms of the chances of returning to work (Fonseca et al., 1993).
Biological variables seem to be of particular importance in the prognosis, namely location and extension of the lesion, etiology, and the initial gravity of the aphasic profile (Basso, 1992).
According to several authors, (Poeck et al., 1989; Basso, 1992; Mazzoni, 1995), speech therapy influences recovery positively. Acknowledgement of its efficacy has been confirmed over the last years in functional neuroimaging studies (Small et al., 1998; Musso et al., 1999; Léger et al., 2002; Peck et al., 2004).
In 2003, Bhogal and collaborators identified all controlled studies (between 1975 and 2002) through a systematic review of aphasia rehabilitation, selecting just 10 for analysis. They concluded that the positive effect of the therapy occurred above all when it was administered in intensive and brief form.
Classic therapy normally involves two to three weekly sessions, lasting one hour, for an average period of six months.
Since 2005, the Laboratory for Language Studies, in collaboration with the Alcoitão Rehabilitation Medicine Centre, has been carrying out a parallel (with two branches) multicentric clinical trial, controlled and randomized, on the efficacy of intensive speech therapy in patients affected by aphasia of vascular origin (SPIRIT).
The distribution of patients by the two therapeutic branches is determined by the severity of the aphasia. In both groups, patients undergo speech therapy for 100 hours, of which two hours per day, five days a week and for a period of 10 weeks, are in an intensive therapy group, and two 1-hour weekly sessions for 50 weeks in the control group.
Patients are evaluated four times: in the beginning (T0); at 10 weeks (T!), corresponding to the end of the treatment period in the intensive therapy group and to an intermediate evaluation in the group of conventional therapy; at 50 weeks (T”), corresponding to the final stage of control group therapy and to a late evaluation of the intensive group ,and at 62 weeks (T3), which corresponds to a follow-up evaluation of both groups.
Preliminary results seem to point to a more marked and faster improvement of the group subject to intensive speech therapy, which will need to be confirmed with the admission of more subjects in the study.
Since the beginning, 945 patients have been evaluated at the two study centres, but only 2.9% (27 patients) have been included in the study, because they were the only ones who met the inclusion criteria
Of those excluded, 70% were left out due to a single criterion, and 30% due to several.
Of the 655 who were excluded due to exclusively one factor, 43,2% were for diagnostic reasons, 10% because their had non-eligible etiologies, about 8% because they presented a long evolution time and about 28% due to multiple reasons
The extremely reduced number of patients admitted on this study confirms the difficulty in carrying out controlled studies in this field of knowledge, given the presence of so many variables which can influence the course of recovery. Nonetheless, only with methodologically correct studies will we be able to draw truly credible conclusions which will actually help us understand the best way to assist this type of patients who have difficulties in one of the noblest capacities of human beings: communicate
José Fonseca
Laboratory for Language Studies
jfonseca@fm.ul.pt
_______________
Bibliography:
Basso, A. (1992). Prognostic factors in aphasia. Aphasiology, 6 (4), 337-348.
Bhogal, S.K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34 (4), 98-993.
Ferro, J.M. & Madureira, S. (2002). Recovery from cognitive and behavioral deficits. In J. Bogousslavsky (Eds), Long term effects of stroke, (p. 149-181). Marcel Dekker, Inc., New York
Fonseca, J.M.; Farrajota, L., Leal, G. & Castro Caldas, A. (1993). Aphasia tem years later. Journal of Clinical and Experimental Neuropsychology,15 (3), 398.
Hartman, J. (1981). Measurement of early spontaneous recovery from aphasia with stroke. Ann Neurol, 9, 89-91.
Peck, K.K.; Moore, A.B.; Crosson, B.A. Gaiefsky, M.; Gopinath, K.S.; White, K. & Briggs, R.W. (2004). Functional Magnetic Resonance imaging before and after aphasia therapy: shifts in hemodynamic time to peak during an overt language task. Stroke, 554-559.
Pedersen, P.M.; Jorgensen, H.S.; Nakayama, H.; Raaschou, H.O. & Olsen, T.S. (1995). Aphasia in acute stroke: Incidence, determinants and recovery. Annals of Neurology, 38, 659-666.
