Constraint-induced Aphasia Therapy

Constraint-induced Aphasia Therapy (CIAT) is an intensive form of speech therapy used to treat aphasia. It derives from constraint-induced movement therapy (CIMT). When constraint-induced therapy is applied to movement, the participant has to wear a constraint, such as a mitt or sling, on his or her good limb. This forces use of the damaged limb. In constraint-induced aphasia therapy, participants are not allowed to use the verbal crutches they may have developed, such as drawing pictures or pointing. CIAT is based on three principles:

‘In speech 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 2-4 hours of speech therapy a day.1

In short, the patient is not allowed to take the easy way out.Constraint Induced Aphasia Therapy

There is very little in traditional medicine that can help chronic aphasia and sufferers are often advised to use coping strategies. However, by employing compensation strategies, we tend to use healthy brain functions and risk reducing stimulation opportunities for the impaired regions, which can lead to a negative cycle of decreased use resulting in reduced spoken language recovery. This process is often called ‘learned non-use’.2 In 2008, a study into constraint-induced aphasia therapy found that it was possible for an aphasic person to improve his or her communication:

‘Whereas classical wisdom had been that aphasia cannot be significantly improved at a chronic stage, we here review evidence that one type of intensive language-action therapy (CILAT) – constraint-induced aphasia therapy – led to significant improvement of language performance in patients with chronic aphasia. …

Conclusions: We conclude that intensive language action therapy is an efficient tool for improving language functions even at chronic stages of aphasia. Therapy studies using this technique can open new perspectives for research into the plasticity of human language circuits.’3

By forcing patients to find the words, the therapist helps them to build ‘brain maps’, enabling them to connect words with their meanings. For example, some studies have found that an action word like ‘run’ activates the same area of the brain as physically running.4 In other words, hearing the word ‘run’ lights up the same area of the brain as the activity of running. Similarly,

‘Words related to different parts of the body such as lick, pick, and kick activated those brain parts that usually control the actions indicated by the words’ meaning. Leg motor areas were activated by words such as “kick”, arm and hand areas were activated by words like “pick”…’5

Typically, constraint-induced aphasia therapy involves small groups of people with aphasia working together on language exercises and ‘games’.6 During this time they must speak. Participants are not allowed to help their communication by pointing, writing, or using any other non-verbal device. The therapist aims to build connections between words, objects and actions. He or she uses a variety of games, such as card games where the player has to name or describe the picture on the card by speaking. CIAT is very intensive. The treatment can take up to six hours a day, five days a week. Participants must also practice continuously at home.

  • Possible benefits of Constraint-induced Aphasia Therapy for stroke

    Aphasia is common after a stroke. In some cases there is spontaneous recovery, although this is usually limited to the first few weeks. In general, there tends to be little or no recovery after the first year.

    In 2008 there was a systematic review of 10 important studies on constraint-induced aphasia therapy.7 It concluded that CIAT does have benefits for people who suffer from chronic aphasia after a stroke. Reviewers argued that CIAT’s success is due in part to its being so intensive and partly to the fact that participants are forced to use spoken language instead of relying on other forms of communication.

    One of the studies followed 15 participants over 10 days. Results showed the following:

    ‘Language functions improved significantly after training for both groups and remained stable over a 6-month follow-up period. Single case analyses revealed statistically significant improvements in 85% of the patients.’8

    Another study compared CIAT with conventional language therapy. Results showed:

    ‘Although the overall number of therapy hours did not differ, the improvement … achieved by patients with chronic aphasia was significantly greater for intensive language action therapy than for the control regime.’9

  • Arguments against using Constraint-induced Aphasia Therapy for stroke

    In 2006, Dr Tim Shallart and his colleagues agreed that constraint-induced aphasia therapy might be a useful treatment. However, they advised caution. They suggested that CIAT should not begin too soon after a stroke and also pointed out a problem common to many non-mainstream therapies – that CIAT had not been proven by a sufficient number of high-quality clinical trials:

    ‘Preliminary investigations suggest that CIT principles may be effective in aphasia rehabilitation. However, this investigation is only beginning, and we are not able to say any more about its efficacy than that in some cases it appears to be helpful. Not only will further study be needed to confirm that CIT is effective with aphasia, these same studies are needed to confirm its safety. For example, some of the animal work by Dr Tim Shallart and colleagues suggested that intensive CIT may be harmful when performed too early after a stroke. Thus the application of CIT to aphasia rehabilitation must be pursued with both enthusiasm and caution.’10

  • Case histories

    1. ‘After his stroke in February 2003, Ed McNally laboured over single words and mostly used gestures and sounds to communicate. For four weeks he underwent 3½ hours a day of CI aphasia therapy… Today, Ed can speak in paragraphs and with fewer pauses. He is one of two patients who have tried the therapy (as of early 2003).’

    Reference: ‘Constraint-Induced Therapy for Aphasia’. Excerpted from the article, ‘A Rehab Revolution’. Stroke Connection Magazine, September/October 2004

  • Notes and references
    1. ‘Constraint-Induced Therapy for Aphasia’. Excerpted from the article, ‘A Rehab Revolution’. Stroke Connection Magazine, September/October 2004
    2. Kirmess M, Mahe LM, ‘Constraint induced language therapy in early aphasia rehabilitation’. InAphasiology, 2010, 24 (6–8): 725–736, p.726.
    3. ‘Aphasia therapy on a neuroscience basis’ by Friedemann Pulvermuller, Marcelo L Berthier. InAphasiology, 2008 June; 22(6): 6 June 563 – 599.
    4. ‘Aphasia therapy on a neuroscience basis’ by Friedemann Pulvermuller, Marcelo L Berthier. InAphasiology, 2008 June; 22(6): 6 June 563 – 599.
    5. ‘Aphasia therapy on a neuroscience basis’ by Friedemann Pulvermuller, Marcelo L Berthier. InAphasiology, 2008 June; 22(6): 6 June 563 – 599.
    6. ‘A paradigm for language action therapy: Four partners, usually three patients with aphasia and one therapist, sit around a table and have cards in front of them. Two copies of each card are in the game. There are barriers between the partners […] The participants make requests to obtain a twin card for one they already have, follow requests made by others, reject requests if they cannot follow them, or ask back in case there is a comprehension problem. This interaction follows the normal sequence of these speech acts in dialogues, which is indicated schematically at the top.’ (Aphasiology, 2008 June; 22(6): 563–599. Published online 2008 May 21)
    7. ‘Constraint-induced language therapy: A systematic review’ by A Raymer. The ASHA Leader, 2009, Feb. 10, 14(2), 26-27
    8. ‘Long-Term Stability of Improved Language Functions in Chronic Aphasia After Constraint-Induced Aphasia Therapy’ by Marcus Meinzer, Daniela Djundja et al. In Stroke. 2005; 36: 1462-1466
    9. ‘Aphasia therapy on a neuroscience basis’ by Friedemann Pulvermuller, Marcelo L Berthier. InAphasiology, 2008 June; 22(6): 6 June 563 – 599
    10. Cited in ‘Constraint-Induced Language Therapy for Aphasia’. Stroke Connection Magazine, March/April 2006.

Aviva Cohen is the author and CEO of Neuro Hero