Abstract-Patients with chronic aphasia were assigned randomly to a group to receive either conventional aphasia therapy or constraint-induced (CI) aphasia therapy, a new therapeutic technique requiring intense practice over a relatively short period of consecutive days. CI aphasia therapy is realized in a communicative therapeutic environment constraining patients to practice systematically speech acts with which they have difficulty. Patients in both groups received the same amount of treatment (30 to 35 hours) as 10 days of massed-practice language exercises for the CI aphasia therapy group (3 hours per day minimum; 10 patients) or over a longer period of Ϸ4 weeks for the conventional therapy group (7 patients). CI aphasia therapy led to significant and pronounced improvements on several standard clinical tests, on self-ratings, and on blinded-observer ratings of the patients' communicative effectiveness in everyday life. Patients who received the control intervention failed to achieve comparable improvements. Data suggest that the language skills of patients with chronic aphasia can be improved in a short period by use of an appropriate massed-practice technique that focuses on the patients' communicative needs. (Stroke. 2001;32:1621-1626.)

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A speeded lexical decision task was used to investigate word-category deficits in patients suffering from lesions in the right hemisphere and in neurological controls without cortical lesion. In all patients from one group (n = 12), the right frontal lobe was affected causing a left-sided hemiparesis. In the second group (n = 6), lesions primarily affected areas in the right inferior temporo-occipital lobes. Patients with motor deficits due to lesions in the spinal cord or in the periphery served as neurological controls (n = 9). Processing of three categories of words was investigated: verbs referring to actions (action verbs (acVs)); nouns with strong visual associations (visually-related nouns (viNs)); and nouns with both strong action and visual associations (bimodal nouns (biNs)). Stimulus categories were matched for word length and normalized lexical frequency. Error scores revealed a significant word category by patient group interaction. Patients with lesions in the right frontal lobe showed most severe deficits in processing action verbs, whereas those with lesions in their right temporo-occipital areas showed most severe deficits in processing visually-related nouns. Neurological controls did not show any differences between word categories. The double dissociation of the processing impairments seen in frontal versus temporo-occipital patients demonstrates that specific word-category deficits can arise from lesions in the right non-dominant hemisphere. An account for these results in terms of distributed neuronal systems representing words is offered.

Word category-specific deficits were investigated in two patients with right hemispheric lesions and hemiparesis affecting the left extremities. Words from three categories, action verbs, nouns with strong visual associations and nouns with both strong action and visual associations, were presented in a lexical decision task. The stimulus categories were matched for word length and frequency. In both patients, responses to action verbs were slowed and/or less accurate compared with the other word categories. This was so even in the patient with a minor lesion in the motor, pre-motor and somatosensory areas of the hand representation. Control subjects did not show category differences when tested with the same stimulus materials. These results are consistent with the view that the cortical areas involved in the programming of body movements, even those in the hemisphere not dominant for language, specifically contribute to and are necessary for the processing of words referring to such movements. As an alternative, the affected brain areas may be of particular relevance for the processing of words from the lexical category of verbs. The results are consistent with a brain model of language based on Hebb's cell assembly concept.

Zusammenfassung: Gehirnwissenschaftliche Erkenntnisse haben in den vergangenen Jahren zur Entwicklung neuer Therapieformen in der neurologischen und neuropsychologischen Rehabilitationsforschung geführt. Allgemeine Prinzipien, die diesen neuen Verfahren zugrunde liegen, lassen sich mit den Termini Intensivierung, Verhaltensrelevanz und Fokussierung umreißen. Intensivierung der Therapie bedeutet, dass die Intervention mit besonders hoher Frequenz durchgeführt wird (engl.: massed practice). Die neuen Verfahren sind zunehmend verhaltensrelevant, was bedeutet, dass die im therapeutischen Setting implementierten Interaktionstypen denjenigen in alltäglichen Lebenszusammenhängen gleichen (behavioral relevance). Schließlich bedeutet «Fokussierung», dass der Patient durch Hilfsmittel und Regeln der therapeutischen Interaktion zu Handlungsweisen gebracht wird, die er aufgrund operanter Konditionierungen in Folge der Gehirnschädigung sonst vermeiden würde (constraints to avoid learned nonuse). In einer kontrollierten Effektivitätsstudie konnten wir beweisen, dass intensive verhaltensrelevante und fokussierte Sprachtherapie auch bei langjähriger und chronischer Aphasie zu einer signifikanten Verbesserung der sprachlichen Leistungen führen kann -diese Verbesserung manifestierte sich sowohl in klinischen Tests als auch in der Selbst-und Fremdeinschätzung. Wir gehen hier auf die historischen Wurzeln des neuen Verfahrens ein und diskutieren anstehende Fragen für zukünftige Forschungen.Schlüsselwörter: Aphasie, Neuropsychologische Rehabilitation, Intensivierung, Neurowissenschaft englischer Titel fehlt Summary: This article introduces a new approach to neuropsychological therapy of chronic language disturbances called Constraint-Induced Aphasia (CIA) therapy. General principles that are at the heart of the new procedure include massed practice, behavioral relevance, and the application of constraints to prevent learned nonuse. Massed practice implies an intensive application of therapy, with high frequency (several hours per day). In behaviorally relevant therapeutic settings, the practicing of impaired functions is done in a context that resembles everyday activities. The new therapeutic approach uses constraints, for example by introducing rules and instrumental aids, that focus the patient on performing actions he would normally avoid due to aversive conditioning consequent to brain lesion (learned nonuse). In a controlled clinical trial, we were able to demonstrate the success of CIA therapy, a new therapeutic approach that follows all these general principles, in stroke patients with chronic language disability. We address the theoretical foundations of CIA therapy, its historical roots and some issues for future research.

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