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• W2148072426 abstract "HomeStrokeVol. 41, No. 7The ‘Standard’ for Poststroke Aphasia Recovery Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessEditorialPDF/EPUBThe ‘Standard’ for Poststroke Aphasia Recovery Argye E. Hillis Argye E. HillisArgye E. Hillis From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Md, and the Departments of Physical Medicine and Rehabilitation and Cognitive Science, Johns Hopkins University, Baltimore, Md. Search for more papers by this author Originally published10 Jun 2010https://doi.org/10.1161/STROKEAHA.110.585364Stroke. 2010;41:1316–1317Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 10, 2010: Previous Version 1 See related article, pages 1485–1488.The past 2 decades may be remembered as the decades of metrics in medicine. All aspects of our work have been measured and charted by relative value units, H-indices, case mix indices, mean lengths of stay, mean patient satisfaction scores, and so on. Some metrics are important, some less so. However, 1 important measure is the degree to which a patient with stroke will be able to improve in the next 90 days. Decisions need to be made about whether to apply for disability, move to assisted living, or whether to wait for improvement to occur. We as stroke neurologists think we know the answers, but we all give different answers based on very little data; we often say it depends on the size of the stroke, the patient’s age and education, the severity and type of the deficit, the quality and duration of therapy, and so on. However, seemingly within a wide range of these variables, Lazar and colleagues1 have found that that there is a single answer that does not depend on any of these variables; by 90 days, patients improve by approximately 70% of the maximum potential recovery (the maximum potential language score minus their initial score) as long as they receive at least some language therapy if they have significant aphasia after stroke. This study provides 2 very important metrics: (1) a standard against which aphasiologists can measure all new therapies in the subacute phase of stroke (up to 90 days) to determine if they are more effective than the “standard of care” (ie, have added value); and (2) a standard against which providers can measure alternatives to typical therapies. I provide examples of each.First, numerous investigators have proposed that typical speech therapy is provided in “homeopathic doses” and that intensive therapy would be more effective than the typical 30 minutes twice a week therapy often provided. There is some evidence in favor of this conclusion.2–8 Others have proposed that medications such as cholinesterase inhibitors, dextroamphetamine, caffeine,9–14 or transcranial magnetic stimulation15 or direct cortical stimulation16 might augment speech and language therapy. One elegant way to demonstrate the added value of these interventions would be to graph the improvement of the people in the augmented therapy along the graph that Lazar and colleagues have provided in Figure 1 in their paper. If the augmented therapy is better, the patients in the new therapy group should fall clearly above the 95% CIs, reaching significantly >70% of their maximum potential. In the same way, inspection of Figure 1 shows that the 1 patient who falls outside of the 95% CIs in the original study (in this case below the expected improvement) was the 1 patient who had significant aphasia but received no therapy. This patient provides evidence that at least some therapy is essential to meet the expected level of recovery (perhaps to “trigger” the recovery as Lazar and colleagues speculate).Other speech-language pathologists have proposed unique service delivery models to meet unmet needs such as patients in remote areas. These include telemedicine therapy programs, computer treatment programs, group treatment, treatment by a trained family member, and so on. Again, patients who receive treatment through these unique treatment programs can simply be compared against the standard provided by Lazar and colleagues to show that the innovative therapy is noninferior. If the patient’s recovery at 90 days is within the expected range centered around 70% of their maximum potential, then it can be considered within the standard of care. If, like the 1 case who did not receive therapy, the outcome falls below the 95% CIs of the expected range, the treatment approach would be considered inferior to the standard of care.Some caveats are important. First, severely aphasic patients were excluded from this study on the basis that they could not give consent. The same reasoning was given for excluding children from research at one time. If we are going to learn how to help people with severe aphasia, we must include them. It is possible to obtain informed consent from their closest relatives and obtain assent from the individuals themselves in future studies to determine if these data apply also to people with severe aphasia.A second caveat is that we do not really know from this study if the quality or duration or frequency of therapy would have made a difference, because we know nothing about the therapy that was provided. It is quite likely that it was relatively infrequent for short periods after 1 week or so of acute inpatient rehabilitation for those who also had need for physical and occupational therapy. However, many patients with significant aphasia have no physical and occupational therapy needs, so they never have inpatient therapy or indeed any intensive therapy. As noted earlier, there is independent evidence from other studies that intensive therapy may be more effective and might have allowed the patients in this study to reach a higher outcome than 70% of their maximum potential.The composite outcome measure they chose was reasonable, because it was based on the subtest scores of the Western Aphasia Battery with the highest interrater reliability on the Western Aphasia Battery. However, it does not capture all aspects of speech and language that might be both targets of therapy and important aspects of recovery to patients. For example, it does not capture speech articulation or “fluency,” which is notoriously hard to measure, because fluency is a multidimensional parameter that reflects grammatical aspects of sentence production, pauses, articulatory struggle and accuracy, prosody, and so on. Even experienced speech-language pathologists using the Western Aphasia Battery scoring have poor interrater reliability in scoring fluency.17 The composite score also does not capture reading, writing, or grammaticality of sentence production.In summary, Lazar and colleagues have provided an important metric for predicting aphasia recovery and evaluating interventions for aphasia after stroke. Time will tell how much better we can do than “70% of the maximum recovery by 90 days” with novel augmentative treatments. Importantly, the lifetime after 90 days poststroke provides fertile grounds for further improvement in communication. Individuals with aphasia should be guided toward communication enhancement programs, book clubs, social organizations, or language research (see www.aphasia.org) after traditional aphasia therapy ends.The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Argye E. Hillis, MD, MA, Department of Neurology, Meyer 6-113, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287. E-mail [email protected] References 1 Lazar RM, Minzer B, Antoniello D, Festa JR, Krakauer JW, Marshall RS. Improvement in aphasia scores after stroke is well predicted by initial severity. Stroke. 2010; 41: 1485–1488.LinkGoogle Scholar2 Denes G, Perazzolo C, Piani A, Piccione F. Intensive versus regular speech therapy in global aphasia: a controlled study. Aphasiology. 1996; 10: 385–394.CrossrefGoogle Scholar3 Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke. 2003; 34: 987–993.LinkGoogle Scholar4 Bhogal SK, Teasell RW, Foley NC, Speechley MR. Rehabilitation of aphasia: more is better. Top Stroke Rehabil. 2003; 10: 66–76.CrossrefMedlineGoogle Scholar5 Pulvermuller F, Neininger B, Elbert T, Mohr B, Rockstsorn B, Koebbel P, Taub E. Constraint-induced therapy of aphasia after stroke. Stroke. 2001; 32: 1621–1626.CrossrefMedlineGoogle Scholar6 Basso A. How intensive/prolonged should an intensive/prolonged treatment be? Aphasiology. 2005; 19: 975–984.CrossrefGoogle Scholar7 Hillis AE. Treatment of naming disorders: new issues regarding old therapies. J Int Neuropsychol Soc. 1998; 4: 648–660.CrossrefMedlineGoogle Scholar8 Brindley P, Copeland M, Demain C, Martyn P. A comparison of the speech of ten Broca’s aphasics following intensive and non-intensive periods of therapy. Aphasiology. 1989; 3: 695–707.CrossrefGoogle Scholar9 Albert ML, Bachman DL, Morgan A, Helms-Estabrooks N. Pharmacotherapy in aphasia. Neurology. 1988; 38: 877–879.CrossrefMedlineGoogle Scholar10 Ashtary F, Janghorbani M, Chisaz A, Reisi M, Bahrami A. A randomized, double blind trial of bromocriptine efficacy in nonfluent aphasia after stroke. Thirty-eight patients were treated for 4 months. Neurology. 2006; 66: 914–916.CrossrefMedlineGoogle Scholar11 Huber W, Willmes K, Poeck K, Van Vleyman B, Deberdt W. Piracetam as an adjuvant to language therapy for aphasia: a randomized, double blind, placebo controlled pilot study. Arch Phys Med Rehabil. 1997; 78: 245–250.CrossrefMedlineGoogle Scholar12 MacLennan DL, Nicholas LE, Morley GK, Brookshire RH. The effects of bromocriptine on speech and language function in a man with transcortical motor aphasia. Clinical Aphasiology. 1991; 21: 145–155.Google Scholar13 Martinsson L, Hardemark HG, Wahlgren NG. Amphetamines for improving stroke recovery: a systematic Cochrane review. Stroke. 2003; 34: 2766.LinkGoogle Scholar14 Walker-Batson D, Curtis S, Natarajan R, Ford J, Dronkers N, Salmeron E, Lai J, Unwin DH. A double-blind, placebo-controlled study of the use of amphetamine in the treatment of aphasia. Stroke. 2001; 32: 2093–2098.CrossrefMedlineGoogle Scholar15 Martin PI, Naeser MA, Theoret H, Tormos JM, Nicholas M, Kurland J, Fregni F, Seekins H, Doron K, Pascual-Leone A. Transcranial magnetic stimulation as a complementary treatment for aphasia. Semin Speech Lang. 2004; 25: 181–191.CrossrefMedlineGoogle Scholar16 Kakuda W, Abo M, Kaito N, Watanabe M, Senoo A. Functional MRI-based therapeutic rTMS strategy for aphasic stroke patients: a case series pilot study. Int J Neurosci. 2010; 120: 60–66.CrossrefMedlineGoogle Scholar17 Trupe AE. Reliability of rating spontaneous speech in the Western Aphasia Battery: implications for classification. In: Brookshire RH, ed. Clinical Aphasiology. Minneapolis, MN: BRK Publishers; 1984: 55–69.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Yu Q, Sun Y, Liao X, Qian W and Ye T (2022) Integrity of the Left Arcuate Fasciculus Segments Significantly Affects Language Performance in Individuals with Acute/Subacute Post-Stroke Aphasia: A Cross-Sectional Diffusion Tensor Imaging Study, Brain Sciences, 10.3390/brainsci12070907, 12:7, (907) Osa García A, Brambati S, Brisebois A, Désilets-Barnabé M, Houzé B, Bedetti C, Rochon E, Leonard C, Desautels A and Marcotte K (2020) Predicting Early Post-stroke Aphasia Outcome From Initial Aphasia Severity, Frontiers in Neurology, 10.3389/fneur.2020.00120, 11 Yu Q, Wang H, Li S and Dai Y (2019) Predictive role of subcomponents of the left arcuate fasciculus in prognosis of aphasia after stroke, Medicine, 10.1097/MD.0000000000015775, 98:23, (e15775), Online publication date: 1-Jun-2019. Sebastian R, Tsapkini K, Tippett D and Parente R Transcranial direct current stimulation in post stroke aphasia and primary progressive aphasia: Current knowledge and future clinical applications, NeuroRehabilitation, 10.3233/NRE-161346, 39:1, (141-152) M.M. W and S.A. B (2015) Factors predicting post-stroke aphasia recovery, Journal of the Neurological Sciences, 10.1016/j.jns.2015.03.020, 352:1-2, (12-18), Online publication date: 1-May-2015. Conklyn D, Novak E, Boissy A, Bethoux F and Chemali K (2012) The Effects of Modified Melodic Intonation Therapy on Nonfluent Aphasia: A Pilot Study, Journal of Speech, Language, and Hearing Research, 10.1044/1092-4388(2012/11-0105), 55:5, (1463-1471), Online publication date: 1-Oct-2012. Marchina S, Zhu L, Norton A, Zipse L, Wan C and Schlaug G (2011) Impairment of Speech Production Predicted by Lesion Load of the Left Arcuate Fasciculus, Stroke, 42:8, (2251-2256), Online publication date: 1-Aug-2011. Jung I, Lim J, Kang E, Sohn H and Paik N (2011) The Factors Associated with Good Responses to Speech Therapy Combined with Transcranial Direct Current Stimulation in Post-stroke Aphasic Patients, Annals of Rehabilitation Medicine, 10.5535/arm.2011.35.4.460, 35:4, (460), . July 2010Vol 41, Issue 7 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.110.585364PMID: 20538691 Originally publishedJune 10, 2010 KeywordsprognosisaphasiaPDF download Advertisement" @default.
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