Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint

Abstract

Purpose Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical. Method Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality. Results All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant. Conclusion Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials

“…Ciccone N et al [ 35 ] did not find the superiority of distributed CIAT (45–60 minutes/session, 20 sessions for 5 weeks) over the control training with the same dosage for stroke patients at very acute phase. Sickert A et al [ 31 ] found both groups showed improvement compared with the baseline, however, no significant difference was noted in any outcomes between two group, which was similar in the study of Kurland et al Wilssens I et al [ 30 ] showed that the CIAT positively affected the language production and phonology, while the group of BOX posed more beneficial effects on the language comprehension and semantics, and Kurland J et al [ 42 ] found that the CIAT gained better generalization into the untrained words, compared with the PACE group, in picture naming (23.4% for CIAT and 15.2% for PACE, p <0.001) ( Table 2 ).…”

“…One study [ 41 ] compared the therapist-led and layperson-led CIAT, so we excluded it. Finally, eight RCTs were included in this review [ 19 , 27 – 31 , 35 , 42 ]. ( Fig 1 )…”

“…Four studies [ 30 , 31 , 35 , 42 ] and Woldag H et al’s [ 27 ] trial compared the CIAT and other intensive speech therapy programs (same intensity as the CIAT but without the component of constraint). Wilssens I et al and Kurland J et al [ 30 , 42 ] focused on the chronic aphasia, while Ciccone N et al [ 35 ] and Sickert A et al [ 31 ] explored the CIAT for patient with acute and subacute stroke, respectively. Wilssens I et al [ 30 ] only enrolled patients with fluent aphasia.…”

“…Also, we noted that some benefits were from the constraint, rather than the unconstraint strategies. William I et al [ 30 ] showed the CIAT group gained more benefits in the language production, relatively to the BOX group with the same treatment intensity and Kurland J et al [ 42 ] mentioned that CIAT may help achieve better generalization to untrained pictures in naming tasks, relatively to the unconstraint treatment with the same high-intensity. It is hard to conclude whether the “constraint” is useful based on RCTs included in this review, however, exploring the special effects from the “constraint” in different aspects of language is still worth in further studies.…”

Playing a team game improves word production in poststroke aphasia

“…These protocols share the following defining characteristics: (1) Treatment is delivered in small groups (up to three patients); (2) practice is strictly focused on a verbal, spoken output with other forms of communication either not practiced or actively discouraged (constrained); (3) treatment is intensive where intensity refers to the therapy being delivered both with a high-dose and in a compact way (massed rather than distributed practice); (4) treatment is focused on word production (picture naming); (5) treatment involves shaping, where word production is practiced repeatedly, with different carrier sentences, and different degrees of facilitation; (6) naming is promoted in the context of social requests as part of a card game (Go Fish) where participants ask other participants for matching cards. CIP have received a lot of attention because studies have shown benefits for treated words and, occasionally, improvements on standardized tasks (e.g., Carpenter & Cherney, 2016;Pulvermüller et al, 2001; for a review, see Zhang et al, 2017; but also see for negative results-Attard, Rose, & Lanyon, 2012;Hameister, Nickels, Ca, & Croot, 2017;Kurland, Stanek, Stokes, Li, & Andrianopoulos, 2016;Nickels & Osborne, 2016). Which elements are responsible for the success of CIP, however, remain unclear.…”