NEURO REHAB BASED ON THE LATEST RESEARCH

Evidence-based practice is an approach to rehabilitation intended to optimize decision-making and form of treatment by emphasizing the use of evidence from high evidence research data in the form of meta-analyses, systematic reviews and randomised controlled trials that are used to design guidelines and policies. 

Evidence-based medicine advocates that decisions and policies should be based on evidence, which is supplemented with knowledge from the scientific literature so that best practice can be determined and applied. It promotes the use of formal, explicit methods to analyze evidence and makes it available to decision makers.

Our certified therapists are continuously trained to utilise the latest scientific knowledge. In partnership with universities in Europe, Casa Afasia conduct research on neurorehabilitation.

NamnlospngCOOPERATION WITH KAROLINSKA INSTITUTE AND CIMES APHASIA LAB, UNIVERSITY OF MALAGA

CASA AFASIA partake in an ongoing science project the Karolinska Institute and with professor Marcelo Berthier and his aphasia research group on Cimes Aphasia Lab, University of Malaga examining the results from intensive rehab in behavioural data and brain morphology.  

http://cimes-sna.uma.es/cimes-sna/Inicio.html

BACKGROUND
Growing knowledge about factors promoting neuroplasticity has had a large impact on neurological rehabilitation in later years. The previous, common assumption that improvement of function after a stroke or a traumatic brain injury only could be accomplished during a limited period of time post injury has been challenged. Instead it has been shown that the brain is plastic and improvements and new learning can take place many years after the injury (Lee & Cherney, 2008; Berthier & Pulvermüller, 2011; Breitenstein et al., 2017). The mechanisms related to recovery, reorganization and brain plasticity are yet far from clearly understood and neurobiological correlates of therapy-induced plasticity changes need further studies (Hartwigsen & Saur, 2017). New methods for treatment of aphasia based on principles promoting neuroplasticity have been developed over the last decade, such as Constraint-Induced Aphasia Therapy (CIAT, nowadays ILAT) (Pulvermüller & Berthier, 2008; Pierce et al., 2017), and Intensive Comprehensive Aphasia Programs (ICAP:s), offered in Canada, US and Australia (Rose et al., 2013). The latest Cochrane-review on effects of speech and language pathology intervention for aphasia following stroke concluded that more intensive intervention is beneficial, but further research is needed to identify optimal dose and intensity. It is also not yet clarified if any specific method or type of intervention is more beneficial (Brady et al., 2016).  

The Swedish National Board of Health and Welfare published new national guidelines for stroke care in 2018 (Socialstyrelsen, 2018). According to the national guidelines intensive aphasia treatment shall be provided (priority 3) (4-15h/week) while low intensive treatment (classified as 2-3 h/week) can be offered (priority 7). The stroke guidelines conclude that intensive treatment has better effect on both linguistic function as well as functional communication compared to less intensive interventions. Aphasia rehabilitation in accordance with these guidelines is not sufficiently available in Sweden. Access to aphasia rehab is also not evenly distributed over the country, as reported by the Swedish Aphasia Foundation (Afasiförbundet, 2015). According to the latest available information, long-term or intensive treatments are seldom offered to people with aphasia, but updated information is not available (Blom Johansson et al., 2011). This creates negative impact for people with communication deficits who are not provided with opportunities for optimal care and improvements. Lack of resources is likely one factor behind unevenly distributed and insufficient care, but obstacles for providing evidence-based interventions has not been clearly identified. The Swedish Institute for Health Economics reports that the total yearly cost for stroke is 16.1 billion of which 4.2 billion are directly related to costs for health-care. Creating and following rehabilitation guidelines are cost-effective both for the patients and the society. Evidence based intensive intervention has proven to be more cost efficient than traditional therapy (Wenke et al., 2014).  

Specific research questions are:

1.     What structural and functional neuroplasticity changes following intensive rehabilitation of AOS can be identified and how do they correlate to speech-language outcomes?

2.     What functional connectivity changes can be detected and how do they correspond with speech-language and cognitive outcomes following intensive rehabilitation?

METHOD

Study 1 and 2: Neuroimaging studies of structural and functional changes following intensive language rehabilitation

Participants:

30 participants are consecutively recruited from Casa Afasia. Inclusion criteria: Age 18 or older, minimum 6 months post stroke onset, remaining aphasia and/or AOS diagnosed by a speech-language pathologist. Exclusion criteria are severely impaired vision and/or hearing preventing participation in rehabilitation, documented symptoms of cognitive disease and presence of metal implants or severe claustrophobia preventing the MRI-scanning.

Data-collection, speech-language assessment

Assessment of speech and language and communicative functions before and after intensive speech-language intervention with a follow up 8 weeks post intervention. Background information about time since onset, sex, age, handedness, hemiparesis, number of strokes and eventual earlier rehabilitation will be documented to allow further analyses of treatment outcomes. The test battery includes: CAT (Comprehensive Aphasia Test) (Swinburn, Porter, & Howard, 2004), BNT (Boston Naming Test) (Kaplan, Goodglass & Weintraub, 1983), TAX (Test for Apraxia of Speech) (Hybbinette, 2018), CETI (Communicative Effectiveness Index) (Lomas et al, 1989) and MFS (Mental Fatigue Scale) (Fisk et al., 1994).

The assessments are filmed in order to study inter- and intrarater reliability of test scoring. All assessors (professional speech and language therapists) are trained in administration and scoring of the outcome measures and closely supervised by the trial coordinator.

Data-collection, neuroimaging:

Pre and post speech-language intervention, magnetic resonance imaging (MRI) scans will be performed on a 3-T MRI scanner. Voxel based morphometry analysis as well as resting state functional connectivity analysis will be completed to assess structural and functional changes following intervention. All neuroimaging data and analysis will be performed at Malaga

Intervention:

Intensive speech and language treatment following the MIRA-program with a minimum of three hours therapy daily during two weeks, in total a minimum of 30 hours therapy combined with physiotherapy.

Data Analyses:

The treatment effects will primarily be evaluated with tests for repeated measurements (for example ANOVAs or Friedman’s test for non-parametric data). Analyses of neuroimaging data will be performed at the Molecular Imaging Unit, University of Malaga.

REFERENCES

-Berthier, M. L., & Pulvermüller, F. (2011). Neuroscience insights improve neurorehabilitation of poststroke aphasia. Nature Reviews Neurology, 7(2), 86–97


-Blom Johansson, M., Carlsson, M., & Sonnander, K. (2011). Working with families of persons with aphasia: a survey of Swedish speech and language pathologists. Disability & Rehabilitation, 2011, 33(1), 51–62

-Brady, M.C., Kelly, H., Godwin, J., Enderby, P., Campbell, P. (2016). Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev, 1(6)


-Breitenstein, C., Grewe, T., Flöel, A., Ziegler, W., Springer, L., Martus, P., ... Baumgaertner, A. (2017). Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded- endpoint, controlled trial in a health-care setting. The Lancet, 389(10078), 1528–1538

-Duffy JR (2013). Motor Speech Disorders, 3rd Edition, Mosby


-Flowers, H. L., Skoretz, S. A., Silver, F. L., Rochon, E., Fang, J., Flamand-Roze, C., & Martino, R. (2016). Poststroke aphasia frequency, recovery, and outcomes: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 97, 2188–2201


-Graham, R.J., et al. (2011). "Aphasia and return to work in younger stroke survivors." Aphasiology 25(8), 952- 960


-Hartwigsen, G & Saur D. (2017). Neuroimaging of stroke recovery from aphasia – Insight into plasticity of the human language network. Neuroimage, xxx, e-pub ahead of print 1-18


-Lam, J.M. & Wodchis W.P. (2010). The relationship of 60 disease diagnoses and 15 conditions to preference- based health-related quality of life in Ontario hospital-based long-term care residents. Med Care., 48(4), 380-7

-Lee, J. B., & Cherney, L. R. (2008). The changing “face” of aphasia therapy. Perspectives on Neurophysiology & Neurogenic Speech & Language Disorders, 18(1), 15–23


-Mitchell, C., Bowen, A., Gittins, M., Vail, A., Conroy, P., Paley, L.Tyson, S. (2018). Prevalence of aphasia and co- occurrence of dysarthria: The UK Sentinel Stroke National Audit Programme. Aphasiology, 32, 145-146


-New, A. B., Robin, D. A., Parkinson, A. L., Duffy, J. R., McNeil, M. R., Piguet, O., ... & Ballard, K. J. (2015). Altered resting-state network connectivity in stroke patients with and without apraxia of speech. NeuroImage: Clinical, 8, 429-439


-Pierce, J.E., Menahemi-Falkov, M., O'Halloran, R., Toghe, L., & Rose, M.L. (2017). Constraint and multimodal approaches to therapy for chronic aphasia: A systematic review and meta-analysis. Neuropsychol Rehabil, 18, 1- 37


-Public Health Agency of Sweden (2014). Folkhälsan i Sverige, Statens Folkhälsoinstitutet


-Pulvermüller, F., & Berthier, M.L. (2008). Aphasia therapy on a neuroscience basis, Aphasiology, 22 (6), 563-599.

-Rose, M. L., Cherney, L. R., & Worrall, L. E. (2013). Intensive comprehensive aphasia programs: an international survey of practice. Topics in Stroke Rehabilitation, 20(5), 379–387


-Socialstyrelsen (Swedish National Board of Health and Welfare). (2018). Nationella riktlinjer för vård vid stroke. (National guidelines for stroke care) Stockholm: Socialstyrelsen


-Wenke, R., Lawrie, M., Hobson, T., Comben, W., Romano, M., Ward, E., Cardell, E. (2014). Feasibility and cost- analysis of implementing high intensity aphasia clinics within a sub-acute setting. Int J Speech Lang Path, 16(3) 250-9