Effectiveness of conventional language therapy in stroke patients

Stroke is a major non-communicable disease of increasing socio-economic importance in aging populations. According to the world health organization (WHO) Global Burden of Disease report, stroke was the second leading cause of mortality worldwide in 1990 & the third leading cause of mortality in developed countries, (1), causing approximately 4.4 million deaths worldwide. (2), the most recent estimates showed that in 2002, the number of deaths due to stroke reached 5.51 million worldwide, with two-thirds of these deaths occurring in developing countries. Stroke also is a major cause of long-term disability, & has an enormous emotional & socioeconomic impact on patient, families & health services.

Speech & language problems are common sequelae of stroke that significantly impact the daily lives of stroke survivors. Reduced speech & language skills have negative ramifications on the individual’s social, vocational & recreational activities, often leading to social isolation, loneliness. Given the importance of communication to the stroke survivor’s quality of life, it is essential that rehabilitation professional’s recognized & address the speech & language disorders associated with stroke.

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Normal speech & language is extraordinarily complex. A number of steps are required, some accomplished sequentially & some in parallel that incorporate the following:

Conceptualization of an idea & generation of a communicative goal.

Formulation of a grammatically structural sequence of verbal symbols (words), each consisting of an interacting set of ordered sounds.

Selection of a series of neural commands (or) sensorimotor “programs” that will activate co articulated times, durations, & intensities

Central & peripheral nervous system innervations of muscles of respiration, phonation, resonance, & articulation to produce the intended acoustic signal.

Stroke can disrupt any of the stages of speech & language, resulting in one (or) more of the disorder of aphasia. Disruption to the initial stage involving the structure & rules of the linguistic message results in aphasia.

Aphasia has been defined as a multimodality language disorder resulting from damage to brain areas that sub serves the formulation & understanding of language & its components (i.e., phonology, syntax, morphology & semantics).

Broca’s aphasia:

It is a motor aphasia (or) non-fluent aphasia. In this type of aphasia, speech output is highly reduced and is limited mainly to short utterances of less than 4 words. The vocabulary access is limited and the sound formation by the patients with Broca’s aphasia is often laborious and clumsy. The patient may understand speech relatively well and also be able to read, but be limited in writing. Broca’s aphasia is often named as a ‘non fluent aphasia’ due to the halting of the speech.

Fluency:

Non-fluent

Slow & effortful output

Short phrase length (less than 4 words)

Disrupted prosody of speech.

Oral Expression:

Agrammatism: Uses primarily substantive content words (nouns, verbs) with few functional words (pronouns, prepositions, articles), most sentences are simplified.

May have an associated apraxia of speech.

Auditory Comprehension:

Relatively good comprehension except for sentences that involve syntactic complexity.

Repetition:

Poor.

Restoration of normal communicational activities of patient is the primary goal of rehabilitation. To reach the aim the physiotherapist can use conventional language therapy and constraint induced language therapy.

Conventional language therapy includes Exercise, Naming, Repetition, sentence completion, following the instructions of therapist and Conversation. The conventional language therapy helps the patient to relearn the simple communicable activities.

Constraint induced language therapy includes Word Games like (i) Material constraint (use of minimal pairs), (ii) Shaping & rule constraints (form sentences), (iii) Reinforcement constraints. The constraint induced language therapy helps the patient to improve the communicable activities.

The combination of conventional language therapy and constraint induced language therapy would bring about excellent improvements in communicational activities.

The commonly used parameter to evaluate the outcome of treatment procedures are the western aphasia battery.

The parameter selected for this study is the western aphasia battery. The pre & post test values of western aphasia battery will be computed in numbers for comparison.

Thus the study intended to compare the effect of conventional language therapy versus conventional language therapy and constraint induced language therapy in improving the communicational activities of stroke patient.

This study facilitates to find out the most effective treatment to improve the communicational activities of stroke patients in society at the earliest.

AIMS AND OBJECTIVES
AIM OF THE STUDY

To compare the effectiveness of conventional language therapy versus conventional language therapy with constraint induced language therapy in the management of post ischemic stroke Broca’s aphasia.

OBJECTIVES OF THE STUDY

To determine the effectiveness of conventional language therapy in the management of post ischemic stroke Broca’s aphasia.

To determine the effectiveness of constraint induced language therapy in the management of post ischemic stroke Broca’s aphasia.

To determine the effectiveness of conventional language therapy versus conventional language therapy with constraint induced language therapy in the management of post ischemic stroke Broca’s aphasia

To find out the effective treatment regarding language functional status in post ischemic stroke Broca’s aphsia.

HYPOTHESIS
NULL HYPOTHESIS

The null hypothesis states that there was no any significant difference between conventional language therapy versus conventional language therapy with constraint induced language therapy in the management of post ischemic stroke Broca’s aphasia.

ALTERNATE HYPOTHESIS

The alternate hypothesis states that there was significant difference between conventional language therapy versus conventional language therapy with constraint induced language therapy in the management of post ischemic stroke Broca’s aphasia

REVIEW OF LITERATURE
1. Pulvermuller F, et. al., (2001)

Conducted a study on patients having chronic aphasia were assigned randomly to one group to receive either conventional language therapy or constraint induced language therapy. Patients in both groups received the same level of treatment (30 to 35 hours) as 10 days of massed practice language exercises for the CILT group ( 3 hours/day minimum; for 10 patients) or over a longer period of approximately 4 weeks for the conventional language therapy group ( 7 patients). CILT led to significant and pronounced improvements on approved clinical tests, on self-ratings, and on blinded observer readings of the patient’s communicative effectiveness in day to day life. Results suggest that the language skills of patients having chronic aphasia can be improved in a short course by the use of an appropriate massed practice method that focuses on the patient’s communicative needs.

2. Swearengin JA, et. al., (2006)

Conducted a pilot study on a group of individuals with chronic aphasia. Here we compared treatment that required forced use of the language modality, CILT, to treatment allowing all modes of communication. Both treatments were administrated intensively, using the same therapeutic stimuli& tasks. The results suggest that whereas both interventions yielded positive outcomes, but CILT group showed more consistent improvement on standard aphasia measures and clinician judgments of narrative discourse. Thus these results findings suggest that CILT intervention may be a viable approach to aphasia rehabilitation.

3. Jerzy P. Szaflarski et. al.,

Conducted a pilot study on three male patients with moderate to severe post-stroke aphasia. They received CILT 3-4 hours per day for 5 successive days. Pre and post testing included formal language evaluation, linguistic analysis of story retell and mini communication activity log. Results showed substantial improvements in comprehension and verbal skills. Thus the results indicate that the CILT is useful tool in language restoration in after stroke.

4. Meinzer M, et. al., (2005)

Conducted a study on 27 patients with chronic aphasia received 30 hours of treatment over 10 days. 12 patients were trained with CILT program, for 15 patients the training included a module of written language and an additional training in everyday communication plus CILT. The outcome measures included standardized neurolinguistic testing. The results showed more pronounced and increased language function for patients of the group CILT plus. Thus this effective intervention can be successfully used in the rehabilitation of chronic aphasia patients.

5. Sanjit K. Bhogal BA et. al.,

Conducted a recent study on aphasic patients had determined that intense aphasia therapy (CILT)over a short period of time has greater impact on recovery than less intense therapy over a longer period of time. Thus this study examines other aspects of aphasia therapy that may be combined to facilitate recovery. Several areas of aphasia therapy have proven to be more effective than others.

6. Cynthia M. Shewan et. al., (2004)

Conducted a study on aphasic patients who received one of three types of speech and language treatment was compared with that in aphasic patients who received no treatment. One hundred aphasic patients were followed from 2 to 4 weeks post on set for 1 year or until recovery, using a standardized test battery administered at systematic intervals. Both treatment methods were provided, while the method provided by trained nonprofessionals approached statistical significance. Small group size prevented resolution of the question of whether one type of treatment was superior to another. Thus the results show that language therapy improves the language status of aphasic patients.

7. Robert Teasell, MD et. al.,

Conducted a study on post stroke aphasic patients. The aim of the study is to evaluate the relationship between the intensity of aphasia therapy and aphasia recovery. Alterations in mean scores from all studies were recorded. Intensity of the therapy was recorded in means of length of therapy, hours of the therapy provided per week, and the total hours of therapy provided. Pearson correlation was used to check the relationship between changes in average scores of outcome measures and the intensity of therapy. Studies that explained a significant treatment effect gave 8.8 hours of therapy per week for 11.2 weeks versus the negative studies that only gave 2 hours per week for 22.9 weeks. On a mean, positive studies provided a total of 98.4 hours of the therapy, whereas the negative studies provided 43.6 hours of the therapy. Total length of therapy time was judged to be inversely correlated with hours of therapy provided per week (P=0.003) and total hours of therapy given (P=0.001). Total length of therapy was inversely correlated with mean changes in Porch Index of Communicative Abilities (PICA) scores (P=0.0001). The number of hours of therapy given in a week was significantly related to greater improvement on the PICA (P=0.001) and the Token Test (P=0.027). Total number of hours of therapy was significantly correlated with higher improvement on the PICA (P<0.001) and the Token Test (P<0.001).Thus intense therapy (CILT) over a short duration of time can improve outcomes of language therapy for stroke patients with aphasia.

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8. Kelly H et. al., (2009)

Conducted a study on person with aphasia. They identified 30 trials involving 1840 randomized participants that were suitable for inclusion in this review. Overall, the review shows evidence from randomized trials to suggest there may be a benefit from speech and language therapy.

9. Karyn pingel et. al., (2010)

Conducted a study on 9 patients with chronic non fluent aphasia and the patients are selected by Nonrandomized control trial. One group is treated with constraint induced language therapy and next one is treated with conventional language therapy. Both groups received treatment 3h/d, 4d/wk for 2 consecutive weeks. The main outcome measure is Western aphasia battery, Boston Naming Test, Action Naming Test, and linguistic analyses. Although participants in both groups evinced positive outcomes post treatment, the results suggest that CILT subjects showed increased performance on more measures than the traditional subjects.

10. Lynn Maher et. al., (2008)

Conducted a study on 48 patients with chronic aphasia. They are randomly assigned for this study. After the treatment session results suggest that individuals with chronic aphasia made substantial, measurable change on a language battery following intensive CILT in regarding with a standardized assessment tool. The main purpose of this study is to investigate the effects of intensive, constraint induced language therapy (CILT) for individuals with chronic aphasia compared with traditional aphasia therapy.

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Berthier ML, et. al., (2009)

Conducted a randomized, double blind, placebo-controlled, parallel group study of both memantine and CILT on chronic post stroke aphasia. Patients were randomized into two groups for interventions after baseline evaluations. The main outcome measure is Western aphasia battery and communicative activity log. In accordance with Western aphasia battery and communicative activity log the best outcomes were achieved combining memantine with CILT subjects.

12.Anastasia Raymer et, al., (2009)

Conducted a study on a small group of patients with aphasia to examine the effectiveness of constraint induced language therapy (CILT), in which they are received CILT. In contrast to other aphasia treatment approaches like conventional language therapy. In CILT improved verbal responses than conventional language therapy in accordance with a standardized measurement tool. It is indicated by increase in assessment score. The treatment is provided on an intensive schedule, up to three hours per day for five days per week. Thus the result was concluded that CILT was useful in rehabilitation of language function in aphasia.

MATERIALS AND METHDOLOGY
MATERIALS

Couch.

Chair.

Pillow.

Token.

Picture cards.

Western aphasia battery scoring sheet.

METHODOLOGY
Study Design

Quasi Experimental Study Design.

Study Setting

The study was conducted at out patient department in J.K.K. Munirajah Medical Research Foundation College of Physiotherapy, Komarapalayam and District Head Quarters Hospital, Erode under the supervision of the concerned authorities

Sampling Method

Convenient sampling method.

Sample Size

Thirty patients with Ischemic Stroke Broca’s aphasia, who comes under the inclusion criteria, were taken for the study.

Study Duration

The study was conducted for a course of 4 months (5 sittings per week).

Inclusion Criteria

Age group – 40-60 years.

Both sexes.

Right-handed persons

Primary Language is Tamil.

Adequate hearing and vision to participate in language therapy

Unilateral Left CVA involvement

Moderate To moderately severe aphasia.

Non-fluent aphasia

Cognition > 11(MMSE).

Exclusion Criteria

Degenerative or Metabolic illness.

Severe depression or psychiatric disorders.

Brainstem stroke.

Recurrent stroke

History of other neurological impairment (e.g. dementia)

Non-Tamil speaking

Deaf and dumb

Severe apraxia of speech.

Parameters

Western Aphasia Battery

Token Test.

Mini Mental State Examination

Porch Index of Communicative Abilities (PICA).

Technique:
Conventional language therapy

Exercises

Naming

Repetition

Sentence completion

Following instructions

Conversations on patients interest topic’s

Constraint induced language therapy

Constraint means: Avoiding the use of compensatory strategies such as gesturing, drawing, writing etc.

Forced use : Means communicating by talking, and

Massed practice : Means 2 to 4 hrs of speech therapy a day.

Word Games

Material constraints

Shaping and rule constraints

Reinforcement contingencies

Procedure

A total number of 30 patients having Ischemic Stroke Broca’s aphasia who met the inclusion criteria were recruited by convenient sampling method. After the informed consent obtained, they were partitioned into two groups as Group A and Group B, with 15 patients in each.

Hence prior to the onset of treatment, pre-tests were conducted using Western Aphasia Battery and results were recorded for both groups.

After a clarifying demonstration about Conventional language therapy, Group A subjects were subjected to Conventional language therapy with supervised for a period of 4 months.

After a clarifying demonstration about Conventional Language Therapy with Constrained induced language therapy, Group B subjects were subjected to Conventional Language Therapy with Constrained induced language therapy for a period of 4 months.

In the last session, a post test was conducted using Western Aphasia Battery and the results were recorded.

In fine, the analysis of the recorded results was carried out for the purposes of comparing the pre-test Vs post-test results, in turn the treatment techniques.

Statistical Tool

The statistical tools used in the study were paired’t’ test and unpaired’t’ test.

Paired’t’ test:

The paired’t’ test was used to find out the statistical significance between pre and post test of patients treated with Conventional Language Therapy and Constrained induced language therapy in Ischemic Stroke Broca’s Aphasia separately.

Formula: Paired’t’ test:

s =

t =

d = difference between pre test Vs post test values

= mean difference

n = total number of subjects

s = standard deviation.

Unpaired ‘t’ test:

The unpaired ‘t’ test was used to compare the statistically significant difference between Group A and Group B.

Formula: Unpaired ‘t’ test:

s =

t =

n1 = total number of subjects in group A

n2 = total number of subjects in group B

= difference between pre test Vs post test of group A

= mean difference between pre test Vs post test of

group A

= difference between pretest Vs post test of group B

= mean difference between pre test Vs post test of

group B

s = standard deviation.

DATA PRESENTATION
TABLE -I
S.No
GROUP- A
Conventional Language Therapy
GROUP- B
Conventional Language Therapy with Constraint Induced Language Therapy
Pre-Test
Post-Test
Pre-Test
Post-Test

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

44

46

42

43

45

44

43

44

49

50

43

44

42

45

45

63

61

69

61

65

65

60

66

70

73

67

66

62

68

69

45

45

42

44

43

50

49

44

43

43

45

43

42

46

44

75

73

75

80

81

80

73

75

75

80

72

80

75

81

82

DATA ANALYSIS AND INTERPRETATION

This portion deals with the analysis and interpretation of the data collected from group A and Group B who underwent Conventional Language Therapy And Constraint induced Language therapy

TABLE – II
Group – A

Table II represents the mean values, mean difference, standard deviation, and paired ‘t’ value between pre test Vs post test values of Patient Rated Broca’s Aphasia Evaluation for group A who have been subjected to Conventional Language Therapy.

Western Aphasia Battery
Mean
Mean difference
Standard deviation
Paired ‘t’ value
Pre test

44.6

21.07

3

26.31

Post test

65.67

It shows the analysis of Broca’s Aphasia Evaluation; the paired ‘t’ value of pre Vs post sessions of group A was 26.31 at 0.05 level of significance, which was greater than the tabulated value of 2.15. This showed that there was a statistical significant difference in between pre Vs post test results. The pre test mean was 44.6, the post test mean was 65.67 and mean difference was 21.07, which showed that there was a decrease in Broca’s Aphasia Evaluation in post test indicating the recovery of selected samples in response to intervention.

Graph I -Western Aphasia Battery Evaluation of Group – A
Pre & Post test values
TABLE – III
Group – B

Table III represents the mean values, mean difference, standard deviation, and paired’t’ value of Broca’s Aphasia Evaluation for group B, who have been subjected to Conventional Language Therapy And Constraint induced Language therapy

Western Aphasia Battery
Mean
Mean difference
Standard deviation
Paired ‘t’ value
Pre test

44.53

32.6

4.29

29.41

Post test

77.3

Table III shows the analysis of Broca’s Aphasia Evaluation; the paired’t’ value of pre Vs post sessions of group B was 29.41 at 0.05 level of significance, which was greater than the tabulated value of 2.15. This showed that there was a statistical significant difference in between pre Vs post test results. The pre test mean was 44.53, the post test mean was 77.13 and mean difference was 32.6, which showed that there was a decrease in Broca’s Aphasia Evaluation in post test indicating the recovery of selected samples in response to intervention.

Graph II – Western Aphasia Battery Evaluation of Group – B
Pre & Post test values
TABLE – IV

Table IV represents the comparative mean values, mean difference, standard deviation, and unpaired’t’ value between group A and group B on Broca’s Aphasia Evaluation.

Western Aphasia Battery
Mean
Mean difference
Standard deviation
Unpaired ‘t’ value
Group A

21.07

11.53

3.7

8.54

Group B

32.6

Table IV shows the analysis of group A and group B with Broca’s Aphasia Evaluation. The unpaired’t’ value of 8.54 was greater than the tabulated unpaired ‘t’ value of 2.05 at 0.05 level of significance which showed that there was statistically significant difference between group A and group B. The mean value of group A was 21.07 and the mean value of group B was 32.6, and the mean difference was 11.53 which showed that there was a greater improvement in group B when compared to group A.

Therefore, the study is rejecting the null hypothesis and accepting the alternate hypothesis.
Graph III – Mean difference of Group A and Group B – Western Aphasia Battery
DISCUSSION

The aim of the study was to compare the effectiveness of Conventional language therapy versus Conventional language therapy with Constraint induced language therapy in improving language function in ischemic stroke Broca’s aphasia.

Based on Berthier ML. et.al., (2009) Karyn pingel et.al., (2010) Studies Western Aphasia Battery was selected as parameter in present study.

In the analysis and interpretation of Language function in group A:

The paired ‘t’ value of 26.31 was greater than the tabulated paired ‘t’ value of 2.15, which showed that there was statistically significant difference at 0.05 level of significance and 14 degrees of freedom between pre and post results. The pre test mean was 44.6, post test mean was 65.67 and mean difference was 21.07, which showed improvements regarding language functional status in response to Conventional language therapy after 4 months.

In the analysis and interpretation of Language function in group B:

The paired ‘t’ value of 29.41 was greater than the tabulated paired ‘t’ value of 2.15, which showed that there was statistically significant difference at 0.05 level of significance and 14 degrees of freedom between pre and post results. The pre test mean was 44.53, post test mean was 77.13 and mean difference was 32.6, which showed improvements regarding language functional status in response to Conventional language therapy with constraint induced language therapy after 4 months.

The results of studies conducted by Jerzy P. Szarflarski.et.al., Meinzer M et.al., Anastasia Raymer, supported the present study in which Conventional language therapy with constraint induced language therapy was given.

IN THE COMPARISON OF GROUP – A AND GROUP – B:
In the analysis and interpretation of Language Function between group A and group B:

In the analysis and interpretation of Language function, the unpaired’t’ value of 8.54 which is greater than the tabulated ‘t’ value of 2.05, at 0.05 level of significance and 28 degrees of freedom, which showed that there was statistically significant difference between the pre test Vs post test results of group A and group B. The mean value of group A was 21.07, mean value of group B was 32.6 and mean difference was 11.53 which showed that there was significant improvements regarding language functional status in group B compared to group A in response to treatment.

Based on the statistical analysis and interpretation of the results, the present study showed that there was significant improvement regarding language functional status based on (increase) in Western Aphasia Battery in patients with Ischemic Stroke Broca’s Aphasia treated with Conventional language therapy with onstraint induced language therapy.

Therefore, the present study is accepting alternate hypothesis and rejecting null hypothesis.
Reason for Improvements in Conventional Language Therapy

It increases the efficiency and strength of language skills.

In conventional language therapy regular exercise and practices are used. It helps to strengthen the weak muscles and to prevent it from further degeneration.

Reactivation of the cortex was due to increased responsiveness of weak inputs from neighboring areas.

It takes over of existing descending pathways from premotor and supplementary motor cortex which is involved in language control.

It used to help a survivor of an aphasic regain his ability to talk, recognize voice patterns and regain the ability to relate words to images.

It helps to regaining control over the voice cords is an important part of therapy.

Reason for improvements in constraint induced language therapy

Constraint induced language therapy is very intensive treatment with sessions lasting for up to 6 hours over the course of 10 days so it gives repeated stimulus to brain.

Constraint induced language therapy principles are motivated by neuroscience insights about learning at the level of nerve cells (synaptic plasticity). So it helps to regain language skills.

Constraint induced language therapy contrasts sharply with traditional therapy by the strong belief that mechanisms to compensate for lost language function should not be used unless absolutely necessary, even in everyday life.

It make coupling between cortical systems for language and action in the human brain and it reverses the elements of learned disuse.

It produces some reorganizational changes during language practice.

Reason for improvements in conventional language therapy with constraint induced language therapy

It enhances both parallel and hierarchical processing with in central nervous system which induced stored areas of the brain and it result in enhancing effective recovery.

It consists of various throat and neck exercises, such as Cognitive Linguistic Therapy.

Cognitive Linguistic Therapy concentrates on the patient’s emotions, coaching them on how to respond to tones of voice or words describing emotions, such as “happy.”

It encourages the patients (“constrained”) to use their remaining verbal abilities to succeed in the communication game.

Here the interaction is guided by communicative need in a language game context, picture cards, and the barriers making it impossible to see other players’ cards, and other materials, so that it induces active participation of patient.

It is believed that CILT works by the mechanism of increased neuroplasticity. By constraining an individual to use only speech, it is believed that their brain can reestablish old neural pathways and recruit new neural pathways to compensate for lost function

SUMMARY AND CONCLUSION
SUMMARY

The aim of the study was to compare the effectiveness of Conventional language therapy alone with combined effect of Conventional language therapy and constraint induced language therapy on language function in Ischemic stroke Broca’s aphasia.

A total number of 30 subjects with Ischemic stroke Broca’s aphasia were selected by convenient sampling method after considering the inclusion and exclusion criteria. Then informed consents were obtained from subjects individually.

Western Aphasia Battery was taken as the parameter. Pre test data were collected for group A and group B patients and computed.

Group A patients were subjected to Conventional language therapy and Group B patients were subjected to Conventional language therapy and constraint induced language therapy for a period of 4 Months. The results of the same parameter were recorded for comparison after four months of treatment.

The paired “t” test was used to compare the pre versus post test results of Group A and Group B separately. The unpaired “t” test was used to compare the mean difference of

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