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Multi-modality aphasia therapy is as efficacious as a constraint-induced aphasia therapy for chronic aphasia: A phase 1 study

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Background: There is an urgent need for treatment comparison studies for chronic aphasia. Two different treatments, Constraint-Induced Aphasia Therapy Plus (CIAT Plus) and Multi-Modality Aphasia Therapy (M-MAT) aim to improve spoken language production through intensive shaping of responses, and social-mediated repetitive practice. CIAT Plus constrains responses to the verbal modality, while M-MAT includes gesture, drawing, writing and reading-based cues to assist production. Aims: This Phase 1 study compared the efficacy of CIAT Plus and M-MAT. The study also aimed to investigate the relationship between treatment responsiveness and participant's aphasia severity and cognitive variables. Methods however, order effects are likely to have played a significant role. Treatment potency was demonstrated with generalisation to noun (8 participants) and verb production (1 participant) in discourse. Overall , CIAT Plus and M-MAT were equally efficacious for these 11 individuals, although six participants expressed preference for M-MAT and three for CIAT Plus. Delayed treatment effects were present in some participants. Future large-scale studies are required to deal with order effects and a participant's variability.
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Multi-modality aphasia therapy is as
efficacious as a constraint-induced
aphasia therapy for chronic aphasia:
A phase 1 study
Miranda L. Rose a b , Michelle C. Attard a b , Zaneta Mok a b ,
Lucette E. Lanyon a b & Abby M. Foster a b c
a Department of Human Communication Sciences, Faculty of
Health Sciences, La Trobe University , Melbourne , Australia
b Centre for Clinical Research Excellence in Aphasia
Rehabilitation , Brisbane , Australia
c School of Health and Rehabilitation Sciences, University of
Queensland , Brisbane , Australia
Published online: 08 Jul 2013.
To cite this article: Miranda L. Rose , Michelle C. Attard , Zaneta Mok , Lucette E. Lanyon
& Abby M. Foster (2013) Multi-modality aphasia therapy is as efficacious as a constraint-
induced aphasia therapy for chronic aphasia: A phase 1 study, Aphasiology, 27:8, 938-971, DOI:
10.1080/02687038.2013.810329
To link to this article: http://dx.doi.org/10.1080/02687038.2013.810329
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Aphasiology, 2013
Vol. 27, No. 8, 938–971, http://dx.doi.org/10.1080/02687038.2013.810329
Multi-modality aphasia therapy is as efficacious as a
constraint-induced aphasia therapy for chronic aphasia:
A phase 1 study
Miranda L. Rose1, 2 , Michelle C. Attard1,2, Zaneta Mok1,2 ,
Lucette E. Lanyon1,2, and Abby M. Foster1,2,3
1Department of Human Communication Sciences, Faculty of Health Sciences,
La Trobe University, Melbourne, Australia
2Centre for Clinical Research Excellence in Aphasia Rehabilitation, Brisbane,
Australia
3School of Health and Rehabilitation Sciences, University of Queensland,
Brisbane, Australia
Background: There is an urgent need for treatment comparison studies for chronic
aphasia. Two different treatments, Constraint-Induced Aphasia Therapy Plus (CIAT
Plus) and Multi-Modality Aphasia Therapy (M-MAT) aim to improve spoken language
production through intensive shaping of responses, and social-mediated repetitive prac-
tice. CIAT Plus constrains responses to the verbal modality, while M-MAT includes
gesture, drawing, writing and reading-based cues to assist production.
Aims: This Phase 1 study compared the efficacy of CIAT Plus and M-MAT. The study
also aimed to investigate the relationship between treatment responsiveness and partici-
pant’s aphasia severity and cognitive variables.
Methods & Procedures: We utilised 11 single-subject multiple baseline designs with a
cross-over for treatment type. Participants had chronic aphasia (17–88 months post onset)
and a range of aphasia severities (WAB AQ 36.2–92.8). Participants named 180 noun and
verb probes three times at pre-, mid-, post-treatments and at 1- and 3-month follow-ups.
Both CIAT Plus and M-MAT were delivered for 32 hours over 2 weeks. Six participants
received M-MAT first while five received CIAT Plus first. Standard case charts were devel-
oped for visual analysis of each participant’s probe results. Within-subject effect sizes
(ESs) were calculated on naming the probe scores. Discourse measures were analysed
with descriptive statistics. Participant’s satisfaction with each treatment type was probed.
Results & Conclusions: A total of 32 (of 44 total) immediate post-treatment ESs reached
small (3), medium (7) or large (22) levels, and ranged from –0.96 to 30.6. Higher ESs were
found for nouns as compared to verbs, and for items treated during the first treatment
phase. The mean ES was comparable for items treated with M-MAT (M =8.00) and
CIAT Plus (M =8.58) and was well maintained at the 1-month follow-up. As a group,
aphasia severity was significantly reduced at the 1-month and 3-month follow-up time
points. WAB AQ change scores immediately post-treatment favoured M-MAT for four
Address correspondence to: Dr Miranda Rose, Department of Human Communication Sciences,
Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia. E-mail: m.rose@latrobe.edu.au
The first author was supported by an Australian Research Council Future Fellowship (FT
100100446) and all authors by a National Health and Medical Research Council, Centre for Clinical
Research Excellence in Aphasia Rehabilitation grant (56935). We thank Jennifer Walsh from Monash
Health for her clinical role.
©2013 Taylor & Francis
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 939
participants and CIAT Plus for five; however, order effects are likely to have played
a significant role. Treatment potency was demonstrated with generalisation to noun
(8 participants) and verb production (1 participant) in discourse. Overall,CIAT Plus
and M-MAT were equally efficacious for these 11 individuals, although six participants
expressed preference for M-MAT and three for CIAT Plus. Delayed treatment effects
were present in some participants. Future large-scale studies are required to deal with
order effects and a participant’s variability.
Keywords: Anomia; Aphasia treatment; Constraint-induced aphasia therapy plus; CIAT
plus; Multi-modality aphasia therapy; M-MAT.
INTRODUCTION
Constraint-induced aphasia therapy (CIAT; Pulvermüller et al., 2001) and its variants,
constraint-induced language therapy (CILT; Maher et al., 2006), constraint-induced
aphasia therapy plus (CIAT Plus; Meinzer, Djundja, Barthel, Elbert, & Rockstroh,
2005) and Intensive Language Action Therapy (ILAT; Pulvermüller & Berthier, 2008)
have been shown to be efficacious for many individuals with chronic aphasia. These
constraint treatments have four major components: massed practice (30 hours of
treatment over 2 weeks), shaping of responses (gradually increasing task and stimuli
complexity), socially driven communication tasks (therapy tasks involve interaction-
based games), and constraint to the verbal modality (nonverbal communication is
restricted or discouraged) (DiFrancesco, Pulvermuller, & Mohr, 2012). Constraint
treatments produce small to medium effect sizes (ESs) calculated on formal tests
of language function (e.g., Aachen Aphasia Test) and statistically significant differ-
ences on client perceptions of everyday communication (Cherney, Patterson, Raymer,
Frymark, & Schooling, 2008; Rose, 2013). Although Barthel et al. (2008, as cited in
Meinzer, Rodriguez, & Gonzales Rothi, 2012) showed significant improvement in the
percentage of complete phrases and complex sentences in picture description and con-
versation after CIAT Plus in 12 participants, there is a little objective evidence on the
impact of constraint treatment on discourse and functional communication (Rose,
2013) (See Meinzer et al., 2012 for a thorough discussion of the current evidence
concerning CIAT).
Since the publication of the CIAT and CIAT Plus studies, questions have arisen in
clinical practice and in the literature concerning the appropriateness of utilising the
well-established nonverbal and multi-modality treatments in aphasia rehabilitation,
and whether constraining responses to the verbal modality is a necessary component
of an effective aphasia treatment (Rose, 2013). A recent systematic review of the effects
of gesture treatments confirmed their general positive effect, although the amount
of additional therapeutic benefit afforded by inclusion of gesture elements remains
unclear (Rose, Raymer, Lanyon, & Attard, in press). Multi-modal treatments exploit
the often preserved drawing, gesture, reading and writing abilities of individuals with
aphasia, either as compensation techniques when spoken communication fails to be
restored or as direct cross modal facilitation techniques to re-establish language and
speech (Rose, 2006). Multi-Modality Aphasia Treatment (M-MAT; Rose & Attard,
2011) is one such treatment addressing the latter aim.
The recent Cochrane review of aphasia treatment efficacy highlighted the lack of
comparative treatment evidence for aphasia and urged researchers to undertake this
work (Brady, Kelly, Godwin, & Enderby, 2012). One recent study compared CIAT
Plus to an unconstrained, intensive, individually-tailored and linguistically oriented
treatment (Model Oriented Aphasia Treatment: MOAT) in a small group pre-post
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940 ROSE ET AL.
design (N =12 MOAT; N =27 CIAT Plus) with people with chronic aphasia (Barthel,
Meinzer, Djundja, & Rockstroh, 2008). Comparable and significant improvements
were demonstrated on the Aachen Aphasia Test after both treatments; however,
greater improvements were found in participant’s perceptions of communication and
written language following the MOAT. In another small group, pre-post study Maher
et al. (2006) compared CILT to small group PACE treatment (Davis & Wilcox, 1985)
in individuals with chronic aphasia (CILT: N =4; PACE: N =5). Importantly, PACE
treatment differs from M-MAT in that the goal of PACE is communication of treated
targets by any means (e.g., gesture, drawing, writing) whereas the goal of M-MAT
is a spoken production but achieved through multi-modal cueing (see Rose, 2013 for
extended discussion). Both groups improved significantly following a treatment, but
the authors argued that there was greater improvement in those treated with CILT.
However, follow-up data were missing for two of the five PACE participants, and
three of the five PACE had severe apraxia of speech thereby seriously confounding
the results.
In a proof of concept study, we examined the comparative effects of CIAT Plus
and M-MAT for two individuals with severe chronic Broca’s aphasia (Attard, Rose, &
Lanyon, 2013). A similar positive effect on treated items was found in both treatments,
with significant increases in Western Aphasia Battery (WAB) Aphasia Quotient (AQ)
(Kertesz, 2007) scores at the 6-week and 3-month follow-up assessments. However,
generalisation of treatment gains to discourse was minimal. One participant indicated
preference for M-MAT.
To date, few treatment studies have included empirical discourse outcome mea-
sures, yet the ultimate aim of aphasia treatments is an improved communication,
rather than a reduced language impairment (Carragher, Conroy, Sage, & Wilkinson,
2012). Further, there has been limited examination of possible impacts of treatment
on quality of life or of participant’s satisfaction with treatment. Thus, it remains
unclear as to the relative efficacy of these two intensive but fundamentally different
treatment types (CIAT and M-MAT), and their relative impacts on functional com-
munication, discourse and quality of life. Such information is necessary to minimise
unnecessary health-care spending and improve patient outcomes and satisfaction with
aphasia intervention.
AIMS AND HYPOTHESES
The primary aim of this study was to compare the efficacy of M-MAT to CIAT Plus
for individuals with chronic aphasia. Based on the small amount of available pilot
data, we hypothesised that CIAT Plus and M-MAT would be equally efficacious in
improving picture-naming abilities and reducing aphasia severity immediately follow-
ing a treatment and at 1-month follow-up. No hypotheses were formed concerning the
impacts of CIAT Plus and M-MAT on discourse or quality of life—rather these inves-
tigations were considered exploratory. The secondary aim was to explore participant’s
variables impacting potential differential responsiveness to treatment. The latter aim
was also exploratory and not hypothesis-driven.
METHOD
Participants
Ethics approval for this study was achieved from the La Trobe University and Monash
Health Human Ethics Committees. Eleven participants were recruited to the study
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 941
following responses to advertisements placed in stroke and aphasia support group
newsletters. Inclusion and exclusion criteria included: single left hemisphere stroke at
least 12 months prior to the study; aphasia without severe apraxia of speech, motor
speech disorder or severe limb apraxia; no history of other neurological disorder or
substance abuse, uncorrected vision or hearing loss; no major depression (screened on
Aphasia Depression Rating Scale; Benaim, Cailly, Perennou, & Pelissier, 2004); not
currently receiving speech-language pathology services; right-handed pre-morbidly (A
Simplified Handedness Questionnaire; Bryden, 1982) English as first and primary lan-
guage. Demographic details of all 11 participants are provided in Table 1. Five females
and six males were recruited to the study, ranging from 21 to 88 months post-onset of
stroke. There were four individuals with mild aphasia (WAB AQ 75–93.8), six with
moderate aphasia (WAB AQ 50–74), and one with severe aphasia (WAB AQ 22–49).
Six participants had Broca’s aphasia, four had Anomic and one had Conduction
aphasia.
Pre-treatment assessment
The type and severity of each participant’s aphasia, speech, communication and
selected cognitive functions were ascertained by the patterns of test results obtained
from a range of standardised assessments (see Tables 1–6 for summarised results)
including the WAB (Kertesz, 2007), Boston Naming Test (BNT) (Goodglass &
Kaplan, 2001), Pyramids and Palm Trees (Howard & Patterson, 1992), Test of Oral
and Limb Apraxia (Helm-Estabrooks, 1992), Apraxia Battery for Adults (Dabul,
2000), Coloured Progressive Matrices (Raven, Raven, & Court, 1995), Rey-Osterrieth
Complex Figure Test (as cited in Lezak, 2012) and the Scenario Test (van der
Meulen, van de Sandt-Koenderman, Duivenvoorden, & Ribbers, 2010). In addition,
a 20-minute semi-structured conversation between the participant and the assessor
was recorded and transcribed verbatim (see Appendix A for probe questions). All
assessments were carried out by the authors, who are qualified speech pathologists
experienced in aphasia assessment. Blinded assessments were not used in this Phase 1
study.
Research design
We utilised 11 single-subject multiple baseline designs with a cross over for treat-
ment order. Six participants (Group 1: RW, SS, BH; Group 2: LV, JP, PK) received
M-MAT first followed by CIAT Plus, while five participants (Group 3: JB, ST, LM,
Group 4: AC, PD) received CIAT Plus first followed by M-MAT. Order of treatments
was randomly assigned. Intensity of treatment was constant across both treatments:
3.25 hours per day/4 days per week/2 weeks +45 minutes of refreshment breaks
each day (32 hours contact for each treatment type; 64 hours total). One week
separated the two treatment phases. All sessions were video-recorded. Assessments
were carried out before treatment (pre-treatment), after the first 2-week treatment
block (mid-treatment), after the second 2-week treatment block (post-treatment),
and at 1-month and 3-months after treatment completion (follow-ups). Four sep-
arate groups of participants undertook the study over a 6-month period. Groups
3 and 4 were co-located and to ease staffing needs, met together for 1 hour per
day in a group of five, due to their similarity in aphasia severity and treatment
targets.
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942 ROSE ET AL.
TAB LE 1
Participant characteristics
Participant Age Gender
Education
(years)
Stroke
type/Lesion side MPO
Pre WAB
AQ
Aphasia
type Limb apraxia
Apraxia of
speech+
Hemi-
paresis Handedness
RW 49 F 15 Left ischemic 77 92.8 Anomic Absent Absent Right Right
SS 59 F 16 Left (type n/a) 25 91.2 Anomic Absent Mild None Right
LV 69 M 15 Left (type n/a) 34 85.6 Anomic None Mild-moderate None Right
JP 64 F 13 Left haemorrhagic 22 77.2 Anomic Moderate Very mild Right Right
BH 39 M 15 Left ischemic 88 63.8 Broca’s Mild Mild Right Right
ST 46 M 16 Left SAH 22 61.5 Broca’s Mild Mild-moderate Right Right
AC 64 F 17 Left ischemic 40 57.4 Conduction Mild Moderate-severe None Right
JB 53 M 15 Left ischemic 17 56.8 Broca’s Mild-moderate Mild-moderate Right Right
LM 74 F 15 Left ischemic 79 51.9 Broca’s Moderate Moderate None Right
PD 56 M 19 Left ischemic 22 50.6 Broca’s Moderate Mild Right Right
PK 66 M 10 Left ischemic 58 36.2 Broca’s None Moderate-severe None Right
MPO: months post-onset; (type NA): type not available; Test of Limb Apraxia (Helm-Estabrooks, 1992); +Apraxia Battery for Adults (Dabul, 2000); SAH: sub-arachnoid
haemorrhage.
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 943
TAB LE 2
Results of language and cognitive testing administered at baseline only
Participant
Assessment BH RW SS LV PK JP JB ST LM AC PD
Pyramids and palm trees1
Total score /52 47 50 51 48 39 49 43 35 46 50 42
Coloured progressive matrices2
Total score /36 35 32 31 34 21 24 33 36 36 36 36
ROCF3
Copy /36 36 33 35 33 25 25 33 36 28 36 36
Recall /36 29.5 13 21 18.5 7 11 27.5 17 9.5 24 25
ROC F =Rey-Osterrieth Complex Figure Test; 1Scores above 48 within normal limits; 2Scores above 23 are
above 50th percentile; score of 21 =35th percentile; 3Copy-scores 30–36 within normal limits, Recall-scores
above 10.5 within normal limits.
Stimuli
Treatment stimuli were black and white line drawings of nouns and verbs taken from
the Object and Action Naming Battery (Druks & Masterson, 2000), the Snodgrass
and Vanderwart’s pictures (Snodgrass & Vanderwart, 1980), and the International
Picture-Naming Project (Szekely et al., 2004). These picture sets were selected as the
items all have good name agreements and are able to be matched for the psycholinguis-
tic properties known to influence word retrieval (e.g., word frequency, imageability,
syllable length, and complexity). Of these items, 80 (40 nouns and 40 verbs) were
trained in CIAT Plus and 80 (40 nouns and 40 verbs) in M-MAT, with 20 items
(10 nouns and 10 verbs) serving as untreated controls. Eight different categories of
nouns were utilised (household objects, clothes, animals, shapes, occupations, food,
transport, body parts): four in CIAT Plus and four in M-MAT. Verbs were 1-, 2- or
3-place (argument), and the number of each was balanced across the two treatment
phases. Three individuals with mild aphasia (RW, SS, BH) who had high baseline
noun- and verb-naming scores worked with an additional set of black and white action
photos previously utilised by Meinzer et al. (2005) in their CIAT Plus studies. These
latter stimuli depict a man and/or a woman carrying out everyday household and per-
sonal tasks (e.g., vacuuming the floor, taking an order in a restaurant; folding washing
etc.). Therefore, the mild group (BH, RW, SS) had two sets of 78 items (39 nouns,
21 verbs, and 18 “Meinzer” sentences), one trained in M-MAT and one for CIAT
Plus.
Probing
Probing of the entire stimulus corpus took place at each phase: three probes at
pretreatment, mid-treatment, and post-treatment; and one probe at each of the 1- and
3-month follow-ups. In addition, probing of the trained stimuli (160 items) took place
for each participant at the beginning of every second-treatment session (80 items were
probed on each occasion, so that the entire treated set of 160 items was probed twice
across each treatment phase). During probing, the items were presented individually
on single-sided, white A4 paper. Scoring criteria are outlined in Appendix B.
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944 ROSE ET AL.
Procedures
The procedures adopted for this trial replicated those of a recent pilot study of
two individuals with severe aphasia (Attard et al., 2013). CIAT Plus, described by
Meinzer et al. (2005), is an extension of constraint-induced aphasia therapy includ-
ing written stimuli and daily home practice (Pulvermüller et al., 2001). M-MAT is
a manualised treatment protocol (Rose & Attard, 2011) where verbal production is
the target. M-MAT replicates the small group, intensive, and shaping elements of
CIAT Plus but differs in including multi-modal cues (gesturing, drawing, writing and
reading the word) to assist verbal production. The verbal targets progressed along
a hierarchy of difficulty (see Appendix C). Stimulus complexity was based on the
range of written word frequency of pictured items. Syntactic complexity spanned
across several levels and progressed according to a participant’s success. In order to
sustain the participants’ interest and motivation during the intensive treatment pro-
gramme, the activities (and carrier phrases, following the introduction of Level 2) were
interchanged at 30-minute intervals. Refreshment/lunch breaks followed each hour of
treatment, where participants casually conversed and were free to rest if they chose.
All six authors conducted the interventions such that two therapists were present
during the all treatment sessions. During treatment, participants named items in the
context of six activities (see Appendix D). They took turns to make and respond
to verbal productions of the pictured items. The stimulus items were presented on
single-sided, white laminated cards—the size of standard playing cards (approximately
6cm×9 cm).
CIAT Plus
The CIAT Plus-cueing hierarchy is outlined in Appendix E. A cardboard visual
barrier (approximately 35 cm→× 49 cm) was placed between the participants. It was
temporarily removed when necessary based on the activity (for example, during the
Board Game when the die was rolled). Participant’s hand movements behind the bar-
rier were neither inhibited nor encouraged on the basis of findings that constraining
gestures may interfere with naming in healthy speakers (Morsella & Krauss, 2004;
Pyers et al., 2010; Rauscher, Krauss, & Chen, 1996).
M-MAT
The M-MAT-cueing hierarchy is outlined in Appendix E. As the primary treatment
objective was to facilitate spoken naming rather than multi-modality communication,
the first step of the cueing hierarchy entailed verbally naming the items. Where possi-
ble, participants generated the gestures for the items or if not, gestures were suggested
by the clinicians, and were generally iconic (portraying a concrete action/object)
(McNeill, Levy, & Pedelty, 1990). Gestures could be produced one-handed to accom-
modate participants with hemiparesis. In the drawing step, the participants were
encouraged to make a simple drawing of the item. In the writing step, the entire
word was shown initially; over time, the clinicians began to reduce the amount of
cues provided.
For both the CIAT Plus and M-MAT conditions, treatment protocol steps (and
cueing hierarchies) were required beyond Step 1 (naming/production) due to the low
levels of pretreatment accuracy (see Figures 1–11).
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 945
CIAT Plus and M-MAT home practice
As part of a simple home programme, participants were assigned individualised
transfer tasks including one or more items exposed during each session. This involved
making a request for an item (e.g., in a local shop) or naming an item in a functionally
relevant setting (e.g., during meal preparation at home). The participants were then
encouraged to discuss their experiences in the following treatment session.
Data analysis
Standard case charts were developed for visual analysis of each participant’s probe
results across all phases of the study (see Figures 1–11). Within subject ESs were cal-
culated on naming probe scores using Busk and Serlin’s (1992) dand a classification
of the magnitude of ES was made with Beeson and Robey’s (2006) suggestions of
small (2.6), medium (3.9) and large (5.8) effects for aphasia therapy. In addition, pre-,
mid-, and post-treatment discourse measures were analysed with descriptive statistics.
A series of paired samples t-tests were used to investigate possible significant differ-
ences in aphasia severity (WAB AQ) for the whole group at 1- and 3- month follow-ups.
A series of Spearman’s rank order correlations were used to investigate the relation-
ships between treatment ESs and pretreatment aphasia severity (WAB AQ), nonverbal
reasoning (Raven’s matrices), memory (Rey Figure delayed), and semantic processing
(Pyramids and Palm Trees).
Descriptive statistics were utilised to describe the discourse results. Each conversa-
tion transcript was analysed for the following: (1) number of substantive nouns and the
mean number of substantive nouns per minute, and (2) number of substantive verbs
and the mean number of substantive verbs per minute. Substantive nouns include all
proper and common nouns except the general nouns as noted by Halliday and col-
leagues (Halliday & Hasan, 1976; Halliday & Matthiessen, 2006), i.e., thing,stuff ,
people,person, animal,creature,place,andsubstance. Substantive verbs exclude auxil-
iaries, all forms of the verbs be,have,do, and any light uses of verbs, e.g., Igaveatalk,
Itakea nap, and I made acopy(Huddleston & Pullum, 2002). Because our specific
interest for this paper lies in propositional content productivity, all comments that the
participants made on the tasks (e.g., I can’t say the word), all qualifiers and modifiers
(e.g., I think I have to go to the shower,I guess it was yesterday), and all mazes, that
is, repetitions, revisions, false starts, and filled pauses Miller & Iglesias, 2010) were
excluded from the analyses.
In order to probe a participant’s satisfaction with each treatment type, immediately
following each treatment phase, participants indicated their overall satisfaction levels
on a 10-cm likert scale (0 very unsatisfied—10 very satisfied) with pictorial supports
at the anchors adapted with permission from the Communication Disability Profile
(Swinburn & Byng, 2006). They were also encouraged to provide verbal comments,
which were transcribed verbatim.
Reliability and treatment fidelity
Inter- and intra-rater reliabilities were investigated on 10% of the video-recorded probe
data results. In addition, a speech pathologist not involved in providing the therapy
reviewed 10% of video recordings/live sessions (viewed behind one-way mirror) that
were randomly selected and indicated whether the treatment protocols were being
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946 ROSE ET AL.
followed. Further, the therapy team met to review the protocols and participant’s
progress in the daily debriefing sessions.
RESULTS
Point-to-point inter- and intra-rater reliabilities were found to be 95.3% and 96.5%
respectively. Treatment fidelity was reported to be 100% accurate. Figures 1–11 display
the individual probe results. Tables 2–6 show the results of standardised tests across
all phases of the study, and Table 7 shows the ESs for probes across time. Table 8
shows the discourse results and Table 9 displays the participant’s satisfaction scores
and comments.
Primary outcome measure: Noun and verb probes
As expected with this heterogenous group of participants, Table 7 shows that variable
ESs were demonstrated for noun and verb probes across participants. A total of 32 (of
44 total) immediate post-treatment ESs reached small (3), medium (7) or large (22) lev-
els, and ranged from –0.96 to 30.6. All participants demonstrated at least one probe
ES that reached at least the small level. Overall, higher effect sizes ESs were found for
nouns as compared to verbs, and for items treated during the first treatment phase
100
80
60
Percent correct
40
20
0
1 4 5 12, 14 18, 20 24 27 29 32, 34 39, 41
Day
CIAT Plus
treatment
M-MAT
treatment
Pre treatment
46 50 51 78 133
100
80
60
Percent correct
40
20
0
1 4 5 12, 14 18, 20 24 27 29 32, 34 39, 41
Day
46 50 51 78 133
Nouns/39
Verbs/21
Sentences/57
Figure 1. Comparative baseline, treatment and follow-up probe results for BH.
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 947
100
80
60
Percent correct
40
20
0
1 2 3 14, 1620, 22 27 28 31 34, 36 41, 43
Day
CIAT Plus
treatment
M-MAT
treatment
Pre treatment
50 51 52 80 141
1 2 3 14, 1620, 22 27 28 31 34, 36 41, 43
Day
50 51 52 80 141
100
80
60
Percent correct
40
20
0
Nouns/39
Verbs/21
Sentences/57
Figure 2. Comparative baseline, treatment and follow-up probe results for RW.
(15/22 ESs higher for probes treated in first condition) (see bolded figures Table 7).
The mean ESs across all participants were comparable for items treated with M-MAT
(M =8.00) and CIAT Plus (M =8.58). These ESs were reasonably well maintained at
the 1-month follow-up probe.
Secondary outcome measures
WAB AQ results
All participants demonstrated improvement on the WAB AQ on at least one
time point. Previously, a 5-point change score on the WAB AQ has been classified
as clinically significant (Katz & Wertz, 1997), although this was a rather arbitrary
determination. A recent Rasch analysis has suggested variable standard error of
measurement (SEM) for WAB AQ according to aphasia severity in a U-shaped dis-
tribution ranging from <2 points (AQs 30–70) to >6(AQ<20; AQ >90) (Hula,
Donovan, Kendall, & Gonzales Rothi, 2010). In this study, we chose a somewhat con-
servative AQ change score of 3 points overall and/or a 1-point change on either the
fluency or information rating score to reflect treatment responsiveness (see bolded text
Tables 3–6). Using these criteria, all participants responded to the treatments; how-
ever, AC did not respond to treatment on these criteria until the 3-month follow-up
point (although AC was not present for 1-month follow-up). Changes were more pos-
itive in WAB information content (8 participants improved) as compared to WAB
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948 ROSE ET AL.
100
80
60
Percent correct
40
20
0
1 4 5 12, 14 18, 20 24 27 29 32, 34 39, 41
Day
Da
y
CIAT Plus
treatment
M-MAT
treatment
Pre treatment
46 50 51 101, 112 172
1 4 5 12, 14 18, 20 24 27 29 32, 34 39, 41 46 50 51 101, 112 172
100
80
60
Percent correct
40
20
0
Nouns/39
Verbs/21
Sentences/57
Figure 3. Comparative baseline, treatment and follow-up probe results for SS.
fluency scores (3 participants improved), possibly reflecting the lexical basis of the
interventions.
As a group, aphasia severity was significantly reduced at the 1-month follow-up
time point (M =71.55, SD =17.67) as compared to pretreatment (M =66.27,
SD =18.30); t(10) =3.474, p=.006), and also at the 3-month follow-up time point
(M =70.48, SD =16.98); t(10) =4.276, p=.002). There was no significant differ-
ence between 1- and 3-month follow-up WAB AQ scores (t(10) =0.852, p=.414),
indicating maintenance of improvement for the group.
A comparison of individual WAB AQs immediately following M-MAT as
compared to immediately following CIAT Plus revealed four participants favoured
M-MAT (>2 point WAB AQ difference) and five participants favoured CIAT Plus.
However, order effects are likely to have played a significant role. Seven partici-
pants achieved greater WAB AQ change scores following the first treatment than
following the second treatment phase (as compared to mid-phase scores). Seven
of the 11 participants continued to show improvement in WAB AQ scores follow-
ing the second treatment phase, five participants (BH, RW, LV, JP, JB) showed still
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 949
100
80
60
Percent correct
40
20
0
1 4 15 37, 39 44, 46 51 51, 53 53 57, 64 66, 69 71
Day
CIAT Plus
treatment
Control
M-MAT
treatmentPre treatment
71, 76 76 108 157
Nouns/40
Verbs/42
100
80
60
Percent correct
40
20
0
100
80
60
Percent correct
40
20
0
1 4 15 37, 39 44, 46 51 51, 53 53 57, 64 66, 69 71
Day
71, 76 76 108 157
1 4 15 37, 39 44, 46 51 51, 53 53 57, 64 66, 69 71
Day
71, 76 76 108 157
Nouns/40
Total nouns and verbs/20
Verbs/38
Figure 4. Comparative baseline, treatment and follow-up probe results for LV.
further improvement at the 1-month follow up, and two (LV, AC) showed even fur-
ther improvement at the 3-month follow up, suggesting some delay in the treatment
effect.
Best and poorest responders: WAB and probe ESs
Taking into account both the WAB AQ change scores at 1-month compared to base-
line, and the average probe ESs across both treatment phases (for nouns and verbs) for
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950 ROSE ET AL.
100
80
60
Percent correct
40
20
0
1 3 5 38, 40 44, 46 50 51 53 58, 65 67, 70 71
Day
CIAT Plus
treatment
Control
M-MAT
treatment
Pre treatment
73 77 108 157
100
80
60
Percent correct
40
20
0
1 3 5 38, 40 44, 46 50 51 53 58, 65 67, 70 71
Day
73 77 108 157
1 3 5 38, 40 44, 46 50 51 53 58, 65 67, 70 71
Da
y
73 77 108 157
Nouns/40
Verbs/42
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Verbs/38
Figure 5. Comparative baseline, treatment and follow-up probe results for PK.
each individual, the best responders were PK and BH (6.5- and 15.9-point WAB AQ
changes; 15.6- and 14.2-average ESs respectively). The poorest responders were JB and
PD (4.8- and 0.4-point WAB AQ changes; 3.19- and 4.06-average ESs respectively).
Discourse results
Results from the semi-structured conversations are summarised in Table 8. Results
for the participants who initially received M-MAT followed by CIAT Plus (BH, RW,
SS, JB, LV, PK) are discussed first. Following M-MAT, a notable increase (>0.5 per
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 951
100
80
60
Percent correct
40
20
0
1 3 4 15, 18 22, 24 29 30 32 36, 38 43, 45 50
Day
CIAT Plus
treatment
Control
M-MAT
treatment
Pre treatment
52 59 87 136
1 3 4 15, 18 22, 24 29 30 32 36, 38 43, 45 50
Day
52 59 87 136
1 3 4 15, 18 22, 24 29 30 32 36, 38 43, 45 50
Day
52 59 87 136
100
80
60
Percent correct
40
20
0
Nouns/40
Verbs/42
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Verbs/38
Figure 6. Comparative baseline, treatment and follow-up probe results for JP.
N/A=Not assessed.
minute change) in the rate of substantive noun production was observed for RW, JP
and PK while SS and LV demonstrated a decrease. Little change in the rate of sub-
stantive noun production was observed for BH. Following CIAT Plus (the second
treatment), there were decreases in the rate of substantive noun production for RW
and SS, and a notable increase for PK. As for substantive verbs post-M-MAT, only
SS increased her rate of production; JP’s rate of production remained similar and
decreases were observed for the other participants. Following CIAT Plus, there was a
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952 ROSE ET AL.
N/A = Not assessed
100
80
60
Percent correct
40
20
0
1 3 5 16, 18 22, 24 29 30 31 36, 38 N/A
Day
M-MAT
treatment
Control
CIAT Plus
treatment
Pre treatment
50 58 60 81 142
1 3 5 16, 18 22, 24 29 30 31 36, 38 N/A
Day
50 58 60 81 142
1 3 5 16, 18 22, 24 29 30 31 36, 38 N/A
Day
50 58 60 81 142
100
80
60
Percent correct
40
20
0
Nouns/40
Ver b s/ 40
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Ver b s/ 40
Figure 7. Comparative baseline, treatment and follow-up probe results for JB
general downward trend in the rate of substantive verb production for all participants
with the exception of PK.
For the participants who received CIAT Plus first (AC, JB, LM, PD, ST), there was
a notable increase (>0.5 per minute change) in the rate of substantive noun production
for JB and ST and a small increase for AC and LM. After the second treatment phase
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 953
N/A = Not assessed
100
80
60
Percent correct
40
20
0
1 3 16 28, 30 35, 37 41 42 45 49, 51 56, 58 62
Day
M-MAT
treatment
Control
CIAT Plus
treatment
Pre treatment
63 64 90, 91 154
1 3 16 28, 30 35, 37 41 42 45 49, 51 56, 58 62
Day
63 64 90, 91 154
1 N/A N/A 28, 30 35, 37 41 42 45 49, 51 56, 58 62
Day
63 64 90, 91 154
100
80
60
Percent correct
40
20
0
Nouns/40
Ver b s/ 40
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Ver b s/ 40
Figure 8. Comparative baseline, treatment and follow-up probe results for ST.
(M-MAT), both LM and PD demonstrated notable increases in the rate of substantive
noun production, with a small increase noted for AC and a small decrease for JB.
As for substantive verbs, there was a small decrease in the production rates for all five
participants after CIAT Plus, and this slight downward trend continued after M-MAT
(2nd treatment) for all participants, except for ST.
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954 ROSE ET AL.
100
80
60
Percent correct
40
20
0
1 2 3 8, 10 14, 16 22 23 24 28, 30 35, 37 50
Day
M-MAT
treatment
Control
CIAT Plus
treatment
Pre treatment
51 52 62 129
1 2 3 8, 10 14, 16 22 23 24 28, 30 35, 37 50
Day
51 52 62 129
1 2 3 8, 10 14, 16 22 23 24 28, 30 35, 37 50
Da
y
51 52 62 129
100
80
60
Percent correct
40
20
0
Nouns/40
Verbs/40
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Verbs/40
Figure 9. Comparative baseline, treatment and follow-up probe results for LM.
N/A=Not assessed.
CETI, scenario test and SAQOL results
Tables 3–6 display the CETI, Scenario Test and SAQOL results for all participants.
The SEM of the change score in the CETI psychometrics study (Lomas et al., 1989)
was 5. 87. In the current study all participants’ CETI scores increased between pre-
and post-assessment above this SEM from between 6 to 33 points (median =8),
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 955
100
80
60
Percent correct
40
20
0
1 7 8 16, 18 21, 23 28 31 32 35, 37 42, 44 49
Day
M-MAT
treatment
Control
CIAT Plus
treatment
Pre treatment
52 53 N/A 144
1 7 8 16, 18 21, 23 28 31 32 35, 37 42, 44 49
Day
52 53 N/A 144
1 7 8 16, 18 21, 23 28 31 32 35, 37 42, 44 49
Day
52 53 N/A 144
100
80
60
Percent correct
40
20
0
Nouns/40
Verbs/40
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Verbs/40
N/A = Not assessed
Figure 10. Comparative baseline, treatment and follow-up probe results for AC.
indicating enhanced carer-perceptions of a participant’s communication, except JB
whose score decreased by 3 points. Two participants demonstrated change on the
Scenario Test indicating positive change in verbal and gesture-based communication
of scenarios (BH: 12 points; LM: 9 points).
Larger SAQOL scores indicate improved quality of life (Hilari, Byng, Lamping, &
Smith, 2003). Five participants showed increased SAQOL Communication sub-scale
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956 ROSE ET AL.
100
80
60
Percent correct
40
20
0
1 4 16 30, 32 36, 38 44 N/A N/A 50, 52 N/A 63, 70
Day
M-MAT
treatment
Control
CIAT Plus
treatment
Pre treatment
70 71 92, 99 150, 155
1 4 16 30, 32 36, 38 44 N/A N/A 50, 52 57, 59 63, 70
Day
70 71 92, 99 150, 155
1 4 16 30, 32 36, 38 44 N/A N/A N/A N/A 63, 70
Day
70 71 92, 99 150, 155
100
80
60
Percent correct
40
20
0
Nouns/40
Verbs/40
100
80
60
Percent correct
40
20
0
Nouns/40
Total nouns and verbs/20
Verbs/40
N/A = Not assessed
Figure 11. Comparative baseline, treatment and follow-up probe results for PD.
scores following treatment as compared to baseline (BH, RW, PD with 20–30 per-
centile point increases and SS, and LV with percentile point increases of 5), while
three (RW, JP, JB) showed improved Psychosocial sub-scale scores of 10–25 percentile
point increases.
Participant’s satisfaction with M-MAT and CIAT Plus
Overall, participants were satisfied with the two treatments but varied in their
preferences. Taking the satisfaction scores and comments together, six participants
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 957
TAB LE 3
Results of language and cognitive testing at pretreatment, immediate post-treatment and 1- and 3-month follow-up points (BH, RW, SS)
BH RW SS
Assessment Pre-Tx Post-M Post-C+1 mo. 3 mo. Pre-Tx Post-M Post-C+1 mo. 3 mo. Pre-Tx Post-M Post-C+1mo. 3mo.
WAB-R
Aphasia quotient 63.8 66.2 72.3 79.7 67.1 92.8 91.9 96.1 97.6 96.8 91.1 95.2 92.2 94.7 94.1
Spontaneous speech
Information content /10 5 5 7989810 10 10 10 10 10 10 10
Fluency /10 5 66669999999999
Auditory verbal comprehension
Total score /10 8.3 8.0 7.6 8.85 8.05 10 9.7 10 10 10 9.2 9.3 9.2 9.75 9.75
Repetition
Total score /10 6.1 7.3 7.2 7.6 7.0 10 9.7 10 10 10 8.6 9.3 8.6 9.3 9.2
Naming and word finding
Total score /10 7.5 6.8 7.2 8.4 7.1 8.4 9.4 9.1 9.8 9.4 8.9 9.3 9.3 9.3 9.1
Object naming /60 49 44 49 53 42 57 59 58 60 58 57 59 56 60 58
Word fluency /20 8 12 11 16 15 7 15 13 18 16 16 14 17 13 15
Sentence completion /10 10 8 10 8 7 10 10 10 10 10 9 10 10 10 10
Responsive speech /10 8 4 2 7 7 10 10 10 10 10 7 10 10 10 8
BNT
Total score /60 21 27 42 38 33 44 59 53 55 57 51 56 53 52 50
Scenario test
Total score /54 32 41 44 −− 54 54 54 −− 54 54 53 −−
CETI
Total score /100 79 87 86 −− 60 60 73 −− 68 78 −−
SAQOL
Communication /5 2.57 3.43 −− 3.14 3.71 −− 44.14 −−
Psychosocial /555−− 3.1 3.91 −− 54.55 −−
Pre-Tx =Pretreatment; Post-M =Post-M-MAT; Post-C+=Post-CIAT Plus; 1 mo. =1-month follow up; 3 mo. =3-month follow up; – =data not obtained; WAB-R
=Western Aphasia Battery–Revised; BNT =Boston Naming Test; CETI =Communicative Effectiveness Index; SAQOL =Stroke and Aphasia Quality of Life; Bolded
figures: treatment responsiveness (see text).
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958 ROSE ET AL.
TAB LE 4
Results of language and cognitive testing at pretreatment, immediate post-treatment and 1- and 3-month follow-up points (LV, PK, JP)
LV PK JP
Assessment Pre-Tx Post-M Post-C+1 mo. 3 mo. Pre-Tx Post-M Post-C+1 mo. 3 mo. Pre-Tx Post-M Post-C+1mo. 3mo.
WAB-R
Aphasia quotient 85.6 87.6 88.9 89.1 89.9 36.2 45.2 52.9 42.6 49.3 77.2 81.1 81.6 82.4 80.6
Spontaneous speech
Information content /10 10 10 10 10 10 3 575789999
Fluency /10 9 9 9 9 9 4 4 4 4 4 6 6 6 6 6
Auditory verbal comprehension
Total score /10 8.0 9.2 8.75 8.85 9.35 5.7 7.1 8.05 7.2 7.15 8.7 8.85 9 8.9 9.2
Repetition
Total score /10 9.3 8.9 9.4 9.4 9.3 3.2 2.7 2.8 1.2 2.1 9.2 9.8 9.8 9.8 9.4
Naming and word finding
Total score /10 6.1 6.7 7.3 7.3 7.3 2.2 3.8 4.6 3.9 4.4 6.7 6.9 7 7.5 6.7
Object naming /60 42 43 50 44 46 12 24 27 25 29 46 46 42 48 39
Word fluency /20 2 6 4 9 7 6 5 8 5 6 5 7 9 7 9
Sentence completion /10 7 10 9 10 10 0 3 4 3 2 8 8 10 10 10
Responsive speech /10 10 8 10 10 10 4 6 7 6 7 8 8 9 10 9
BNT
Total score /60 28 40 39 44 41 3 5 9 11 4 18 30 32 30 29
Scenario test
Total score /54 54 54 51 −−38 38 38 −− 48 45 48 −−
CETI
Total score /100 93 98 99 100 100 28 31 28 31 36 29 41 43 62 55
SAQOL
Communication /54.04.43 −− 3.14 3.14 −− 2.57 2.43 −−
Psychosocial /55.04.91 −− 5.0 4.18 −− 2.73 3.0 −−
Pre-Tx =Pretreatment; Post-M =Post-M-MAT; Post-C+=Post-CIAT Plus; 1 mo. =1-month follow-up; 3-mo. =3 month follow-up; – =data not obtained;
WA B - R =Western Aphasia Battery–Revised; BNT =Boston Naming Test; CETI =Communicative Effectiveness Index; SAQOL =Stroke and Aphasia Quality of
Life; Bolded figures: treatment responsiveness (see text).
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 959
TAB LE 5
Results of language and cognitive testing at pretreatment, immediate post-treatment and 1-and 3-month follow-up points (JB, ST, LM)
JB ST LM
Assessment Pre-Tx Post-C+Post-M 1 mo. 3 mo. Pre-Tx Post-C+Post-M 1 mo. 3 mo. Pre-Tx Post-C+Post-M 1 mo. 3 mo.
WAB-R
Aphasia quotient 56.8 55 53.8 61.5 58.7 65.5 70 65.8 64 65.9 51.9 59.1 60.9 55.6 57.5
Spontaneous speech
Information content /10 755778 887968887
Fluency /10 4 4 4 55 4444444444
Auditory verbal comprehension
Total score /10 7.5 7.2 6.6 6.95 6.85 7.55 8.4 7.9 8.1 7.25 4.8 8.15 7.75 5.9 4.6
Repetition
Total score /10 5.9 5.7 4.8 6.3 5.9 5.8 6.8 5.9 5.6 5.8 4.0 4.6 5.8 5.1 4.6
Naming and word finding
Total score /10 6.0 5.6 6.5 5.5 5.5 7.4 7.7 7.1 7.3 6.9 4 4.8 4.9 4.8 5.5
Object naming /60 42 35 42 34 34 50 50 55 51 48 29 24 29 29 35
Word fluency /20 6 5 7 5 7 7 9 6 4 7 1 6 8 6 6
Sentence completion /10 5 8 8 6 8 7 10 6 8 6 4 8 6 6 6
Responsive speech /10 7 8 8 10 6 10 8 4 10 8 6 10 6 7 8
BNT
Total score /60 7 9 15 11 14 28 40 31 32 38 10 14 7 10 12
Scenario test
Total score /54 48 38 38 −− 42 44 43 −− 33 40 42 −−
CETI
Total score /100 42 41 39 −− 29 62 −− 46 46 52 −−
SAQOL
Communication /533−− 2.71 2.14 −− 3.14 2.86 −−
Psychosocial /544.36 −− 4.18 3.18 −− 4.45 3.8 −−
Pre-Tx =Pretreatment; Post-M =Post-M-MAT; Post-C+=Post-CIAT Plus; 1 mo. =1-month follow up; 3-mo. =3-month follow up; – =data not obtained;
WA B - R =Western Aphasia Battery–Revised; BNT =Boston Naming Test; CETI =Communicative Effectiveness Index; SAQOL =Stroke and Aphasia Quality of
Life; Bolded figures: treatment responsiveness (see text).
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960 ROSE ET AL.
TAB LE 6
Results of language and cognitive testing at pretreatment, immediate post-treatment and 1-and 3-month follow-up
points (AC, PD)
AC PD
Assessment Pre-Tx Post-C+Post-M 1 mo.13 mo. Pre-Tx Post-C+Post-M 1 mo. 3 mo.
WAB-R
Aphasia quotient 57.4 56.3 56.9 62.1 50.6 54.2 54.8 51.0 53.3
Spontaneous speech
Information content /105557465 46
Fluency /10 655633433
Auditory verbal comprehension
Total score /10 8.1 8.95 7.75 8.45 7.6 7.3 6.4 6.8 6.45
Repetition
Total score /10 4.9 3.4 5.2 2.8 3.2 7.9 7.7 7.7 7.7
Naming and word finding
Total score /10 4.7 5.8 5.5 6.8 3.2 2.9 3.3 4.2 3.5
Object naming /60 28 37 38 47 20 12 16 25 20
Word fluency /20 74392 53 34
Sentence completion /104775686107
Responsive speech /10 8 10 7 74 48 44
BNT
Total score /60 10 9 13 18 2 4 0 1 0
Scenario test
Total score /54 46 47 46 −− 30 29 31 −−
CETI
Total score /100 54 60 60 −− 31 44 64 −−
SAQOL
Communication /5 3.43 3.29 −− 2.86 3.86 −−
Psychosocial /5 4.55 4.09 −− 54.64 −−
Pre-Tx =Pretreatment; Post-M =Post-M-MAT; Post-C+=Post-CIAT Plus; 1 mo. =1-month follow up; 3-mo. =3-month follow
up; −=data not obtained; WAB-R =Western Aphasia Battery – Revised; BNT =Boston Naming Test; CETI =Communicative
Effectiveness Index; SAQOL =Stroke and Aphasia Quality of Life; Bolded figures: treatment responsiveness (see text); 1AC was
unavailable during the 1-month follow-up assessment, resulting in a missing data point.
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 961
TAB LE 7
ESs for each treatment phase and at 1-month follow up (M-MAT first treatment for first six participants; CIAT Plus first treatment for second five
participants)
Pretreatment to Post-M-MAT Post-M-MAT to Post-CIAT Plus Post-CIAT Plus to 1-month follow up
Participant Nouns Verbs Nouns Verbs Nouns Verbs
BH 30.6 4.8 8.07 13.28 2.84 4.04
RW 27.71 4.01 0.87 0.29 0.44 0
SS 4.25 4.58 1.0 2.84 0 1.0
LV 15.97 2.13 5.29 5.17 2.39 0.29
JP 28.87 6.35 1.88 9.60 1.06 0.81
PK 14.33 8.37 27.13 12.67 3.5 1.62
Mean (SD) 20.29 (10.45) 5.04 (2.13) 7.08 (10.33) 7.31 (5.36) 0.26 1.29
Pretreatment to Post-CIAT Plus Post-CIAT Plus to Post-M-MAT Post-M-MAT to 1-month follow up
Nouns Verbs Nouns Verbs Nouns Verbs
JB 10.97 1.44 0.35 0 1.75 1.15
ST 21.94 4.58 0.17 0.96 4.04 2.89
PD 5.02 6.13 2.51 2.58 2.31 0.22
LM 5.44 22 7.22 5.67 1.0 0.40
AC 1.88 20.21 3.68 11.84 4.040.41
Mean (SD) 9.05 (7.91) 10.87 (9.51) 2.79 (2.89) 3.83 (5.17) 1.78 1.17
Bold font indicates ES larger than comparison score in reverse treatment phase; 3-month result as 1 month not available due to a participant’s extended travel.
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962 ROSE ET AL.
TAB LE 8
Results for semi-structured conversation
Time (min) Substantive nouns Substantive nouns/min Substantive verbs Substantive verbs/min
Participant Pre-tx Post-C Post-M Pre-tx Post-C Post-M Pre-tx Post-C Post-M Pre-tx Post-C Post-M Pre-tx Post-C Post-M
AC 19:02 22:29 20:10 63 76 72 3.31 3.38 3.57 57 57 46 2.99 2.54 2.28
JB 18:54 19:56 22:16 44 63 43 2.33 3.16 1.93 24 16 17 1.27 0.80 0.76
LM 12:19 19:30 20:07 26 43 55 2.11 2.21 2.73 12 11 3 0.97 0.56 0.15
PD 22:24 n/a 21:04 39 n/a49 1.74 n/a2.33 29 n/a221.29n/a 1.04
ST 21:13 20:30 21:15 74 87 73 3.49 4.24 3.44 9 6 10 0.42 0.29 0.47
Pre-tx Post-M Post-C Pre-tx Post-M Post-C Pre-tx Post-M Post-C Pre-tx Post-M Post-C Pre-tx Post-M Post-C
BH 16:04 22:01 n/a82114 n/a 5.10 5.18 n/a18 13n/a 1.12 0.59 n/a
RW 17:37 22:01 20:52 164 240 180 9.31 10.90 8.63 112 117 105 6.36 5.31 5.03
SS 8:29 21:09 20:06 73 160 96 8.61 7.57 4.78 34 130 64 4.01 6.15 3.18
JP 20:00 17:58 21:12 122 171 136 6.10 9.52 6.41 91 82 93 4.55 4.56 4.39
LV 21:00 20:00 20:35 167 143 179 7.95 7.15 8.11 144 119 99 6.86 5.95 4.81
PK 21:11 20:37 21:35 22 33 52 1.04 1.60 2.41 5370.24 0.15 0.32
Pre-tx =Pre treatment; Post-C =Post CIAT Plus; Post-M =Post-M-MAT; Bolded figures represent increases from baseline.
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 963
TAB LE 9
Participant’s treatment satisfaction scale results (/100) and comments
Participant
M-MAT
satisfaction
CIAT Plus
satisfaction Comments
BH 84 81.7 No preference, enjoyed both equally, liked barriers, liked
writing, reading, drawing, gesture
RW 80 75.4 I liked M-MAT better because the three people could
communicate together. It gave you many ways to try to
solve the problem. You could use gestures, write it down,
try to say it, and a number of other ones. You might get
it from the other people there at times too. I like CIAT
[Plus] but the other one is better (gestures). CIAT
[Plus]you got to use the words over and over and you
didn’t get to look at the people.
SS 79.5 54.3 Preferred M-MAT because it’s the barriers I can’t talk, yes
I can talk but the three of us in ...to talk. Because I
don’t think that is the barriers. Its laughing and you
because I don’t see the barrier ...I am alone on the
barrier, I can’t see the other persons. I have to raise my
voice (more effort).
LV 87.4 92.6 I enjoyed both of the treatments. They were different, but
because I improved in both, I’m pleased with the results.
PK 100 100 I preferred CIAT Plus because I talked more
JP 89.1 91.4 I preferred CIAT Plus because I liked to practice talking
more but I didn’t like having the barriers up. It felt
unnatural.
JB 71.4 75.5 No comments
ST 68 90 I preferred the M-MAT therapy, CIAT Plus was OK but I
like M-MAT because I could talk to other people.
MMAT was helpful
LM 77 64 Preferred M-MAT- it was hard but good for me
AC 75.5 68.5 Preferred M-MAT because I can write things and its good
PD 88.6 62.5 Unable to comment
preferred M-MAT (RW, SS, ST, LM, AC, PD) and three preferred CIAT Plus (PK,
JP, JB), while two had no clear preference (BH, LV). One person (SS) found the CIAT
Plus visual barriers extremely disconcerting while another preferred to have them (BH)
as they afforded him privacy as he struggled to produce words.
Relationships between ES and aphasia severity, semantic knowledge,
memory and non-verbal reasoning
No significant correlations were found between ESs calculated from combined noun
and verb naming probes, and aphasia severity (WAB AQ) (rs=–0.282, p=.401),
auditory comprehension (WAB Auditory Comprehension) (rs=–.0236, p=.484),
semantic knowledge (Pyramids and Palm Trees), (rs=–0.105, p=.759), non-verbal
reasoning (Raven’s Matrices) (rs=–0.195, p=.565), or visual memory (Rey Figure
delayed) (rs=–0.436, p=.18).
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964 ROSE ET AL.
DISCUSSION
This well-controlled, Phase 1 study directly compared M-MAT and CIAT Plus—
two intensive but fundamentally different treatments—for 11 individuals with chronic
aphasia of varying severities. The rationales for the two treatments are opposing: con-
straint to the verbal modality in CIAT Plus versus multi-modal support for verbal
production in M-MAT.
M-MAT and CIAT Plus are equally efficacious
The group results of the primary outcome measure from this study suggest M-MAT
and CIAT Plus are equally efficacious (overall combined noun and verb probe ESs
8.0 vs 8.58 respectively) but order effects (15/22 ES’s higher for probes treated in first
condition) may have masked clear differences and further large-scale investigations are
warranted. A range of secondary outcome measures provided insight into the effects
of treatment on aphasia severity, discourse, perceptions of functional communication,
and quality of life.
Both M-MAT and CIAT Plus were found to significantly reduce aphasia severity
as measured by WAB AQ, with changes ranging from 0.5 to 13.1 at a 3-month fol-
low up. Substantial changes were also shown immediately following the first phase of
treatment, ranging from 1.1 to 9 AQ points, with seven of the 11 participants exceed-
ing the 3-point gain criteria. This degree of change on an omnibus aphasia battery is
encouraging after a relatively brief period of intensive intervention (32 hours), and in
individuals with chronic aphasia (range 17–88 months post-onset). Maintenance of
treatment effects at 1- and 3-month follow ups are extremely encouraging. Discourse
results add further weight to the argument that these treatments are efficacious.
Substantive increases in rates of noun production were seen for eight of the partic-
ipants and for verb production for one participant. Further, all participants, except
those already at ceiling (SS, LV), improved their information scores derived from the
WAB picture description task. Further evidence of treatment efficacy was provided by
large increases in CETI scores (except JB), and communication-related (5 participants)
and psychological-related (3 participants) quality of life ratings (SAQOL).
Participant’s preferences
In this study, six participants expressed a clear preference for M-MAT over CIAT Plus.
The reasons offered included the enjoyment of multi-modal activity as a way of learn-
ing spoken production, practice in multiple ways to solve “communication problems”
that might be useful at a later date when spoken communication breaks down, and
disliking having to communicate behind barriers in CIAT Plus. However, three par-
ticipants enjoyed the heavy focus on repetition and verbalisation in CIAT Plus, with
BH gaining confidence through being behind a barrier. In our previous study (Attard
et al., 2013), one person with severe aphasia also expressed a strong preference for
M-MAT stating it was less frustrating, and more enjoyable than CIAT Plus. Given
the very different participant’s experience provided in these two types of treatment, it
seems important to probe a participant’s views in future studies. Further, therapists
may also have preferences, and such preference could potentially impact treatment
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 965
effectiveness in the clinic environment. In our group of six therapists, all preferred M-
MAT as they found it more interesting, less repetitive and more interactive than CIAT
Plus.
Responsiveness to treatments
Contrary to recent evidence concerning the negative impact of semantic and cogni-
tive impairment on response to aphasia treatment (Lambon Ralph, Snell, Fillingham,
Conroy, & Sage, 2010; van de Sandt-Koenderman et al., 2008), PK had both the lowest
pretreatment Raven’s matrices score and the second lowest Pyramids and Palm Trees
score yet was the second best responder (WAB AQ change, mean noun/verb ES).
Similarly, JB who was a poor responder on most outcome measures, did not have the
poorest aphasia severity, auditory comprehension, semantic knowledge, visual mem-
ory or non-verbal reasoning skills. Thus, in this small phase 1 study, there were no clear
relationships between treatment response and aphasia severity, auditory comprehen-
sion, semantic processing, non-verbal reasoning or visual memory. However, possible
relationships may have been masked by the small sample size. It is also possible that
CIAT Plus and M-MAT include components (such as intensity and socially medi-
ated practice contexts) that work positively to overcome the previously found negative
predictive relationships in prior non-intense and de-contextualised naming treatment
studies. Clearly, much work remains to be done in order to determine the key factors
predicting treatment responsiveness in chronic aphasia.
Nouns more responsive than verbs
In this study, we found that nouns were more responsive to the treatments than verbs
as measured in picture naming probes and in the structural discourse measures. Given
that six of the participants had Broca’s aphasia, and people with Broca’s aphasia have
been found to have greater impairment in verb than noun production (Kemmerer
& Tranel, 2000), perhaps this finding is not surprising. However, two participants
with Broca’s aphasia (LM, PD) had higher ESs with verbs than nouns, and three
participants with anomic aphasia (RW, LV, JP) showed better response on nouns
than verbs. Clearly, producing verbs is a more challenging activity for many peo-
ple with aphasia, and the efficacy of the CIAT Plus and M-MAT treatments should
be carefully examined in future studies in terms of their impact on different word
classes.
Optimal time to measure treatment response in chronic aphasia
One interesting finding from the current study concerns the five participants who
demonstrated a delayed treatment effect at the 1-month follow up (WAB AQ), and
a further two participants who continued to improve up until the 3-month follow up.
In their study of a 1-month long intensive treatment for chronic aphasia, Code, Torney,
Gildea-Howardine, and Willmes (2010) found delayed treatment effects 1 month after
the treatment ceased for 3/7 participants. Similarly, in our pilot study (Attard et al.,
2013) we found delayed response in two individuals with severe chronic aphasia. The
mechanisms of such response delay are not well understood and should be investigated
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966 ROSE ET AL.
more fully in future studies. At the very least, treatment efficacy studies for chronic
aphasia should incorporate 1- and 3-month follow-up periods.
Limitations of discourse measures
In this Phase 1 study, we have based our discourse measures on the number and rate
of noun and verb productions in semi-structured conversations. These measures offer
an evaluation of generalisation from lexical treatments within an interactive game-
based treatment to more spontaneous discourse. However, these measures, based on
structural linguistic units, while providing an assessment of lexical productivity, do not
offer insight to the functional consequences of such generalisation effects. Future stud-
ies should include measures based on more functional-semantic oriented approaches
to discourse.
Limitations of the within subject treatment comparison and the need
for large-scale studies
This study provides novel evidence concerning the relative efficacy of two fun-
damentally different intensive treatments for chronic aphasia. Results suggest the
multi-modal approach utilised in M-MAT was efficacious as the constraint approach
in CIAT Plus. However, a significant limitation of this Phase 1 study includes possi-
ble order effects present in the cross-over design. Although we attempted to minimise
order effects by counterbalancing the order of treatments across the 11 participants,
aphasia severity was not balanced across the groups and could have introduced a con-
found. In order to appropriately deal with the variability present in the population of
people with aphasia, the possibility of delayed treatment effects, and the likelihood of
treatment primacy effects, future investigations into the comparative efficacy of these
two treatments should be large-scale randomised group studies. Future studies could
also investigate non-intensive versions of these treatments with the possibility of these
being suitable for people with certain aphasia sub-types.
Manuscript received 7 May 2013
Manuscript accepted 28 May 2013
First published online 8 July 2013
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APPENDIX A
Semi-structured conversation pro forma
(1) What have you been doing today?
(2) Can you tell me about your stroke?
(3) Can you tell me about your family?
(4) How did you and your partner meet?
(5) Can you tell me about your friends?
(6) Tell me about your pets (if you have any)—or what pet you would have if you
could (and why)
(7) What sort of work have you done in your life? What has been your favourite and
why?
(8) Can you tell me about your home and/or garden? How did you come to live
here?
(9) What are your hobbies/interests? How did these develop?
(10) What kinds of foods/restaurants do you like?
(11) What sorts of music do you like and why? Have you ever learned to play a
musical instrument?
APPENDIX B
Response scoring criteria
(1) Participant (P) states correct name for item but says something such as, “no ...
or appears very unsure.
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M-MAT VERSUS CIAT PLUS FOR CHRONIC APHASIA 969
Does not choose another name afterwardsCORRECT
Chooses another name afterwardsINCORRECT
(2) P communicates the name for item using an alternative modality
Names the item in the spoken modality before or afterwardsCORRECT
Does not name the item in the spoken modalityINCORRECT
(3) P states correct name for item within a compound word, phrase or sentence (e.g.,
“shoe laces” for “shoe”, “go to the toilet” for “toilet”)
If assessor reminds P to name item and P names item alone; the response does
not dramatically alter the meaning of the word (e.g., “field mouse” for
“mouse”)CORRECT
The meaning of the item has been changed; P shows no awareness of having
said item or is unable to name item aloneINCORRECT
(4) P states the name of an item after that picture has been turned over
Picture has not yet been laid down/attempts at naming of the next item has not
commenced CORRECT
Picture has been laid down/attempts at naming of the next item has commenced
INCORRECT
(5) P states the name of a noun in the form of a verb (e.g., “ironing” for “iron”)
INCORRECT
(6) P states correct name for item but in plural form (e.g., “sandwiches” for “sand-
wich”)
CORRECT
(7) P states name for item with phonemic paraphasia
Word remains guessable and is not ambiguous in meaning (e.g., /paskεtI/for
spaghetti; /ko:rkstru/for corkscrew)CORRECT
Word is no longer guessable or has taken on the form of another word —whether
or not it exists in the treated body of stimuli (e.g., /sta:f/for scarf; /lak/for clock;
/tæp/for cap)INCORRECT
(8) P states name for item that is not the one on the probe score sheet /not the one
already trained in therapy
Name is a reasonable alternative name for items (e.g., pullover for jumper; bug
for beetle; beaters for mixer; loo for toilet; father for priest—as the alternative
“father”, i.e., to a child would be unlikely to be pictured clearly)
CORRECT
Name is ambiguous (could mean other things, e.g., fag/smoke for
cigarette/cigar)INCORRECT
Name is not the best description based on the picture (e.g., pope for priest)
INCORRECT
(9) P states the verb, but it is not in present progressive form (e.g., “knock” for
“knocking”)
If item is most obviously a verb even when not in present progressive form (e.g.,
“knock” for “knocking”, “build” for “building”)CORRECT
If item is ambiguous (could be mistaken for an alternative picture of a noun
whether it exists in the set or not) when not in present progressive form (e.g.,
“ring” for “ringing”, “cut” for “cutting”, “drill” for “drilling”) Acknowledge
their near-accurate response and prompt for “So, what is happening?/What is he
doing?” (Try to only provide this type of cue once, i.e., only for the first ambiguous
verb).
If P still unable to produce present progressive verb formINCORRECT
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970 ROSE ET AL.
APPENDIX C
TAB LE A 1
Level of syntactic complexity-moderate-severe participants
Level Description
1 Noun: “Couch” or Verb: “Running”
2 Carrier phrase1+noun e.g., “Do you have a couch?” or Carrier phrase +verb e.g., “Do you
have running?”
3 Name, do you have noun e.g., “Bill, do you have a shoe?” Name, do you have verb e.g., “Bill,
do you have kissing?”
4 Name, do you have a adj +noun e.g., “Bill, do you have a red shoe?” Name, do you have a
sub +verb e.g., “Bill, do you have the girl is kissing?”
1The carrier phrases were: “Do you have a ...”, “I want/need a ...”, and “I bought/saw/have a ...”.
The participants were encouraged to produce accurate carrier phrases with as much support as required,
although incompleteness and/or incorrect use of morphology was accepted if the noun/verb was correct.
TAB LE A 2
Level of syntactic complexity- mild participants
Level Description
1 Name, do you have a noun/verb e.g., “Bill, do you have a shoe?” or “Bill, do you have kissing?”
2 Name, do you have a adj +noun e.g., “Bill, do you have a red shoe?” Name, do you have a
sub +verb e.g., “Bill, do you have the girl is kissing?”
3 Name, do you have a adj +adj +noun e.g.,“Bill, do you have a large, red shoe?”Name, do you
have a sub +ver b +obj e.g., “Bill, do you have the girl is kissing the boy?”
4 Name, do you have a adj +adj +noun+prep phrase e.g., “Bill, do you have a large, red shoe
on the table?” Name, do you have a adj +sub +verb +obj e.g., “Bill, do you have the tall
girl is kissing the boy?”
5 Name, do you have a adj +adj +noun +prep phrase +prep phrase e.g., “Bill, do you have a
large, red shoe on the table in the garden?” Name, do you have a
adj +sub +verb +obj +prep phrase/indirect object e.g., “Bill, do you have the tall girl is
kissing the boy in the garden?”
APPENDIX D
Treatment activites
The following 6 treatment activities were utilised:
(1) Go Fish card game: requesting cards form other players to make pairs.
(2) Memory card game (find pairs of cards in overturned cards on a table) and
announce card names as they are turned over.
(3) Request Role plays: pick up a card, imagine you are in a shop, ask the shop owner
(one of the group members) for the item “I want X please”: or “Do you have X/”.
(4) “I went shopping and bought ....”(add items with each new turn).
(5) Board games (e.g., Snakes and Ladders, Ludo). Announce noun/verb picked up
from card pile before board game turn.
(6) Rapid naming during card game of snap (when two card are the same in a pile,
you slap your hand down before the other group members and win the pile).
(7) Game of “Who am I”. Pick up noun card and describe features of object (place
where used, shape, materials made of) to partners who guess card content and
occupation of user.
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APPENDIX E
TAB LE A 3
CIAT plus cueing hierarchy—example for Level 1
Step Description
1 Participant verbally names item1(e.g., “couch”). If correct, move on to next card (starting at
Level 1, Step 1 again) following partner’s turn to name item. If incorrect, go to Step 2
2 Clinician provides a phonemic cue (e.g., “It starts with /k/”). If correct, move on to next card.
If incorrect, go to Step 3
3 Clinician provides a written cue2(e.g., “couch”) in conjunction with a verbal cue (e.g., “It’s a
couch . . . say ‘couch’”). The participant verbally repeats the name three times with the pictured
item and written cue in view.
1The participants were given up to 10 seconds to respond at each step. 2The written cues were presented in
the same card format as the stimulus items (the text was word processed in Arial Black font with the card
in landscape orientation).
TAB LE A 4
M-MAT cueing hierarchy—example for Level 1
Step Description
1 Participant verbally announces card (noun; e.g., “Couch”)1. If correct, move on to next card
(starting at Level 1, Step 1 again) following partner’s turn to announce card. If incorrect, go to
Step 2
2 Ask participant to make an iconic gesture2and say the word to announce the pictured item.
If item named, move on to next card following partner’s turn. If incorrect, go to Step 3
3 Clinician provides an iconic gesture model3. If item named, move on to next card following
partner’s turn. If participant unable to name item, clinician provides item name and asks
participant to repeat with gesture
4 Ask participant to make a drawing4and say the word to announce the pictured item. Clinician
provides refinement cues as necessary. Then go to Step 5
5 Clinician provides a written (orthographic cue card) model5(word; e.g., couch)+verbal model for
the participant to copy. Then go to Step 6
6 The participant verbally repeats the name three times with the pictured item and written cue in
view
1The participants were given up to 10 seconds to respond at each step. 2Any approximation of the gesture
was positively reinforced by the clinicians. 3Models were provided either to reinforce the gesture produced,
or to indicate that the participant could more closely approximate the desired gesture in instances of incom-
plete or unrelated productions, or no production. 4Any drawing which highlighted the characteristic features
of the item was positively reinforced. 5The written cues were presented in the same card format as the
stimulus items (the text was word processed in Arial Black font with the card in landscape orientation).
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... Constraint-induced Aphasia Therapy Plus (CIAT-Plus) 8 and Multimodality Aphasia Therapy (M-MAT) 9 are intensive, highdose interventions delivered in a small group setting of 2-4 participants, aimed at improving verbal communication. They involve different therapeutic strategies: CIAT-plus preferences speech production and verbal therapist cueing; M-MAT includes multimodal tasks and cues (drawing, gesturing and writing). ...
... CIAT-Plus and M-MAT are hypothesised to rely on different underlying neural recovery mechanisms and may be differentially effective based on aphasia severity. 9 10 Systematic reviews of trials of CIAT-Plus and M-MAT reveal moderate-high effect sizes [11][12][13] but studies are limited by small sample sizes (n<15), inadequate comparator groups, and recruitment and detection bias. Determining the most effective intervention for severitybased and other sub-groups of people with aphasia may lead to improved patient outcomes and reduced healthcare costs. ...
... Our primary hypothesis was that, compared with UC, both CIAT-Plus and M-MAT would lead to significantly reduced aphasia severity immediately post-intervention, with M-MAT superior for mild and severe aphasia, and CIAT-Plus superior for moderate aphasia. 9 10 We further hypothesised that, compared with UC, both treatments would lead to improved word retrieval, functional communication, multimodal communication and quality of life. A tertiary objective (not reported here) was to report on the potential incremental cost-effectiveness of these interventions. ...
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Background While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity. Methods We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs. Results We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI −0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI −0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI −1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up. Conclusions CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses. Trial registration number ACTRN 2615000618550.
... A study that compares the effects of CIAT and multimodal therapy (multimodal aphasia therapy -M-MAT) (Rose et al., 2013) is also interesting. When communicating a message in multimodal therapy, patients are allowed to use all channels (drawing, writing, reading, gesture). ...
... It has been demonstrated that allowing patients to express themselves through various channels (gesture, drawing, writing) leads to greater self-confidence in conversation than denying them this opportunity. Speech and language pathologists also stated that the multimodal method of therapy suits them better and that it is more interesting and dynamic than CIAT (Rose et al., 2013). ...
... Existe un interesante estudio que compara los efectos de la TRIA y la Terapia Multimodal (TMM) (Rose et al., 2013). Al comunicar un mensaje en la terapia multimodal, los pacientes pueden utilizar todos los canales (dibujo, escritura, lectura, gestos). ...
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Aphasia frequently leads to long-term consequences in language and communication. This paper presents an overview of current methods of aphasia treatment, as well as empirical data on their effectiveness and limitations. We surveyed literature by accessing electronic databases of Serbian libraries and by using specialized search engines on the internet. A review of the papers confirmed the existence of numerous methods in the treatment of aphasia today, which we conveniently grouped. The central place in the treatment is occupied by methods aimed at treating specific lan- guage disorders and methods specific to the type of aphasia. Methods that are complementary to language-oriented forms of therapy also need to be examined. There is a growing necessity to better define criteria for the implementation of some therapy methods. We feel that more precise definitions and a more unified methodology are needed to evaluate the efficacy of therapy methods and their verification.
... These findings provide preliminary results on how factors impacting the contextual presence of an embodiment effect can be exploited in what they call 'action observation therapy', and encourage the testing of new action-based treatments to recover language disease (Picano, Quadrini, Pisano, & Marangolo, 2021). Besides action observation therapies, other treatments have already been proposed, based on the interaction between the motor and language systems, including Semantic Feature Analysis therapy (Boyle & Coelho, 1995), personalized observation, execution, and mental imagery therapy (Durand & Ansaldo, 2013;Durand, Berroir, & Ansaldo, 2018;Durand, Masson-Trottier, Sontheimer, & Ansaldo, 2021), gesture production therapies (Goldin-Meadow, Nusbaum, Kelly, & Wagner, 2001;Rose, Attard, Mok, Lanyon, & Foster, 2013) and language-action therapies (Difrancesco, Pulvermüller, & Mohr, 2012;Stahl et al., 2018). In a similar vein, neuromodulation studies have shown that stimulating the motor cortex (Branscheidt, Hoppe, Zwitserlood, & Liuzzi, 2017;Meinzer, Darkow, Lindenberg, & Flöel, 2016) and even cerebellar and spinal cord (see Pisano & Marangolo, 2020) facilitate verb retrieval in PWA. ...
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Embodied theories of cognition consider many aspects of language and other cognitive domains as the result of sensory and motor processes. In this view, the appraisal and the use of concepts are based on mechanisms of simulation grounded on prior sensorimotor experiences. Even though these theories continue receiving attention and support, increasing evidence indicates the need to consider the flexible nature of the simulation process, and to accordingly refine embodied accounts. In this consensus paper, we discuss two potential sources of variability in experimental studies on embodiment of language: individual differences and context. Specifically, we show how factors contributing to individual differences may explain inconsistent findings in embodied language phenomena. These factors include sensorimotor or cultural experiences, imagery, context-related factors, and cognitive strategies. We also analyze the different contextual modulations, from single words to sentences and narratives, as well as the top-down and bottom-up influences. Similarly, we review recent efforts to include cultural and language diversity, aging, neurodegenerative diseases, and brain disorders, as well as bilingual evidence into the embodiment framework. We address the importance of considering individual differences and context in clinical studies to drive translational research more efficiently, and we indicate recommendations on how to correctly address these issues in future research. Systematically investigating individual differences and context may contribute to understanding the dynamic nature of simulation in language processes, refining embodied theories of cognition, and ultimately filling the gap between cognition in artificial experimental settings and cognition in the wild (i.e., in everyday life).
... The Cochrane review by Brady et al. (2016) included high intensity groups that ranged from 4-15 hours per week. There is no standard, but many studies in the past decade have used a dosage of ~30 hours over two weeks (e.g., Rose et al., 2013;Wilssens, et al., 2015), as used in the current study. ...
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Background Hildred Schuell’s approach to aphasia therapy was developed in the 1960’s based on her vast clinical experience. Though few refer to the treatment as “Schuell’s”, her stimulation techniques remain widely used and the variables she describes as important (e.g., intensity and salience) are those that now have empirical evidence in promoting adaptive neuroplasticity. Schuell’s Stimulation Approach (SSA) was designed to be applicable to all severity types. This is compelling given the paucity of treatment options for people with particularly severe aphasia. Aims The aim of the current study is to investigate the viability and efficacy of SSA for individuals with chronic severe aphasia, reported as having “plateaued” following other treatments. Methods One participant with severe Wernicke’s and one with severe mixed transcortical aphasia participated in 30 hours of treatment over ten days. A single subject multiple baseline design across behaviours was employed. The treatment design was based on the SSA guidelines outlined by Coelho et al. (2012), and participant performance was compared pre- and post-treatment on language probes, discourse probes, standardised assessment and caregiver ratings. Results Both participants demonstrated improvement on standardised assessment and trained items; generalisation to untrained items and discourse was limited. Both participants also made subjective improvements according to caregivers and others, and one participant showed a decrease in anosognosia. Conclusions Intensively administered SAA may be a feasible treatment option for motivated individuals with chronic severe aphasia who have ceased to benefit from other therapies.
Article
Purpose: Constraint-induced language therapy (CILT) is an aphasia treatment that incorporates neuroplasticity principles of forced verbal use and high-intensity training to facilitate language recovery in individuals with stroke-induced aphasia (Pulvermüller et al., 2001). The burgeoning CILT literature has led to systematic reviews (SRs) that summarize treatment results. In this project, we appraised the quality and examined findings reported in several SRs to draw conclusions about the effectiveness of CILT. Method: We searched multiple databases for SRs that summarized CILT research for poststroke aphasia. We identified six SRs, among which three summarized findings qualitatively and three included meta-analysis (MA) to quantify results. We rated each SR for methodologic quality using the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2; Shea et al., 2017) and extracted findings across the six SRs. Results: Two reviewers reliably applied the AMSTAR 2 to the six SRs. Although the six SRs generally were conducted with satisfactory rigor, each was lacking two or more critical domains. Descriptive summaries in SRs reported positive effects of CILT for language and communication measures. However, the three MAs showed that effects of CILT often did not surpass those of comparison treatments for naming, comprehension, and repetition measures. MA findings were positive in a review that included all research designs and evaluated treatment effects for trained naming items. Generalized CILT effects for standardized language measures were limited in two other MAs. Conclusions: CILT led to improvements in a variety of language and communication measures. When compared with intensive multimodality treatments, CILT effects were similar, suggesting that training intensity may be the potent factor in CILT outcomes. Future SRs should be implemented with increased rigor across quality rating scale domains to increase confidence in conclusions.
Article
The effect of treatment dose on recovery of post-stroke aphasia is not well understood. Inconsistent conceptualisation, measurement, and reporting of the multiple dimensions of dose hinders efforts to evaluate dose-response relationships in aphasia rehabilitation research. We review the state of dose conceptualisation in aphasia rehabilitation and compare the applicability of three existing dose frameworks to aphasia rehabilitation research - the Frequency, Intensity, Time, and Type principle (FITT), the Cumulative Intervention Intensity (CII) framework, and the Multidimensional Dose Articulation Framework (MDAF). The MDAF specifies dose in greater detail than the CII framework and the FITT principle. On this basis we selected the MDAF to be applied to three diverse examples of aphasia rehabilitation research. We next critically examined applicability of the MDAF to aphasia rehabilitation research and identified the next steps needed to systematically conceptualise, measure, and report the multiple dimensions of dose, which together can progress understanding of the effect of treatment dose on outcomes for people with aphasia following stroke. Further consideration is required to enable application of this framework to aphasia interventions that focus on participation, personal, and environmental interventions and to understand how the construct of episode difficulty applies across therapeutic activities used in aphasia interventions.
Article
Repetitive transcranial magnetic stimulation (rTMS) shows promise in improving speech production in post-stroke aphasia. Limited evidence suggests pairing rTMS with speech therapy may result in greater improvements. Twenty stroke survivors (>6 months post-stroke) were randomized to receive either sham rTMS plus multi-modality aphasia therapy (M−MAT) or rTMS plus M−MAT. For the first time, we demonstrate that rTMS combined with M−MAT is feasible, with zero adverse events and minimal attrition. Both groups improved significantly over time on all speech and language outcomes. However, improvements did not differ between rTMS or sham. We found that rTMS and sham groups differed in lesion location, which may explain speech and language outcomes as well as unique patterns of BOLD signal change within each group. We offer practical considerations for future studies and conclude that while combination therapy of rTMS plus M−MAT in chronic post-stroke aphasia is safe and feasible, personalized intervention may be necessary.
Article
Background: In everyday conversations, a person with aphasia (PWA) compensates for their language impairment by relying on multimodal and material resources, as well as on their conversation partners. However, some social actions people perform in authentic interaction, proposing a joint future activity, for example, ordinarily rely on a speaker producing a multi-word utterance. Thus, the language impairment connected to aphasia may impede the production of such proposals, consequently hindering the participation of PWAs in the planning of future activities. Aims: To investigate (1) how people with post-stroke chronic aphasia construct proposals of joint future activities in everyday conversations compared with their familiar conversation partners (FCPs); and (2) how aphasia severity impacts on such proposals and their uptake. Methods & procedures: Ten hours of video-recorded everyday conversations from seven persons with mild and severe aphasia of varying subtypes and their FCPs were explored using conversation analysis. We identified 59 instances where either party proposed a joint future activity and grouped such proposals according to their linguistic format and sequential position. Data are in Finnish. Outcomes & results: People with mild aphasia made about the same number of proposals as their FCPs and used similar linguistic formats to their FCPs when proposing joint future activities. This included comparable patterns associated with producing a time reference, which was routinely used when a proposal initiated a planning activity. Mild aphasia manifested itself as within-turn word searches that were typically self-repaired. In contrast, people with severe aphasia made considerably fewer proposals compared with their FCPs, the proposal formats being linguistically unidentifiable. This resulted in delayed acknowledgement of the PWAs' talk as a proposal. Conclusions & implications: Mild aphasia appears not to impede PWAs' ability to participate in the planning of joint future activities, whereas severe aphasia is a potential limitation. To address this possible participatory barrier, we discuss clinical implications for both therapist-led aphasia treatment and conversation partner training. What this paper adds: What is already known on the subject PWAs use multimodal resources to compensate for their language impairment in everyday conversations. However, certain social actions, such as proposing a joint future activity, cannot ordinarily be accomplished without language. What this paper adds to existing knowledge The study demonstrates that proposing joint future activities is a common social action in everyday conversations between PWAs and their family members. People with mild aphasia used typical linguistic proposal formats, and aphasic word-finding problems did not prevent FCPs from understanding the talk as a proposal. People with severe aphasia constructed proposals infrequently using their remaining linguistic resources, a newspaper connecting the talk to the future and the support from FCPs. What are the potential or actual clinical implications of this work? We suggest designing aphasia treatment with reference to the social action of proposing a joint future activity. Therapist-led treatment could model typical linguistic proposal formats, whereas communication partner training could incorporate FCP strategies that scaffold PWAs' opportunities to construct proposals of joint future activities. This would enhance aphasia treatment's ecological validity, promote its generalization and ultimately enable PWAs to participate in everyday planning activities.
Article
The purpose of this article was to explore the extent to which nonlinguistic cognitive factors demonstrate a relationship with aphasia treatment outcomes. To that end, we conducted a scoping review to broadly characterize the state of the literature related to this topic. Reporting guidelines from the PRISMA extension for scoping reviews were used to conduct our study, which queried two common databases used in the health science literature, PubMed and Web of Science. Search terms and eligibility criteria are provided. Results are organized by the four nonlinguistic domains of cognition explored across the included studies (i.e., attention, memory, executive functioning, and visuospatial skills). Of 949 unique articles identified from our database searches, 17 articles with 18 distinct studies were included in the final scoping review. Notably, most studies included in the scoping review targeted impairment-based aphasia treatments. Most studies also examined multiple domains of nonlinguistic cognition. A relationship between cognition and poststroke aphasia therapy outcomes was identified in nine of 15 studies addressing executive functioning, four of nine studies examining memory, four of eight studies examining visuospatial skills, and two of five studies exploring attention. The results among included studies were mixed, with few discernible patterns within each of the four cognitive domains, though it appears that the influence of nonlinguistic cognition may depend on the timing (i.e., immediate vs. delayed post-treatment) and type (i.e., trained vs. untrained, generalized) of aphasia therapy outcomes. Future study designs should address maintenance, by including outcome measures at follow-up, and generalization, by including measures of performance on either untrained stimuli or trained stimuli in untrained contexts. Future work should also strive for larger sample sizes, perhaps through collaborations, or prioritize replicability to produce more reliable conclusions.
Article
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Background: Gesture is often used as a modality to promote recovery of communication in aphasia, both as a compensation device and as a facilitator of language recovery. To date, there has been no systematic analysis of the quantitative effects of gesture training for aphasia in light of the quality of the research methods undertaken.
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Background: Anomia is a debilitating symptom of aphasia, which impacts significantly on patient quality of life. There is strong evidence in the literature to indicate that treatments for anomia are successful for individuals with aphasia, including those in the chronic stage. However, numerous limitations exist within the methodologies of relevant studies. It remains unclear which treatments provide optimal benefits for varying types and severities of aphasia.Aims: The primary aim of this study was to compare the effectiveness of two treatments, Constraint-Induced Aphasia Therapy-Plus (CIATplus) and Multi-modality Aphasia Therapy (M-MAT) for noun retrieval in individuals with severe chronic Broca's aphasia. The secondary aim was to investigate whether the use of verbal constraint is an essential element of therapy. We hypothesised that M-MAT and CIATplus would lead to equally improved naming scores for treated stimuli.Methods & Procedures: Two females with chronic Broca's aphasia (CH and MT) participated in the study. We utilised two single-participant, alternating treatment designs with multiple probes. For each treatment participants received 3.25-hour treatment sessions along with 45 minutes social interaction 4 days a week, for 2 weeks (32 hours total). Treatment involved naming items in the context of turn-taking card games and home transfer request tasks. Naming probes and assessments were conducted at baseline, following each treatment, and at 6 weeks and 3 months post treatment.Outcomes & Results: Both participants differed in their responses to the treatments. However, M-MAT proved equally efficacious as CIATplus for naming of treated items. Overall, generalisation was not observed for any of the measures. CH reported enjoying both treatments, while MT preferred M-MAT.Conclusions: As expected, a number of variables are likely to have contributed to differences in participant responses to treatment. Replication with larger, well-stratified samples is required to better ascertain the effects of CIATplus and M-MAT on anomia in different types and severities of aphasia. This information would contribute to the more effective application of client-tailored treatment practices.
Chapter
When people talk they can be seen making spontaneous movements called 'gestures'. These are usually movements of the arms and hands and they are closely synchronized with the flow of speech. Gestures and speech occur in very close temporal alignment and often have identical meanings, or 'idea units' (Kendon, 1980). Yet they express these idea units in fundamentally different ways. While speech is segmented (into phonemes, words, phrases, etc.), gestures are global and synthetic. There is no gesture 'language'. Comparing speech to gesture thus enables us to observe the same idea unit expressed in two different ways at the same time. A comparison of this kind produces an effect on our understanding of the linguistic system and gesture something like the effect of triangulation in vision. Many new details, previously hidden, spring out in the new dimension of seeing. Rather than analytically slicing the person into modules, taking into account gesture encourages seeing something like the entire personality as a single theoretical entity - thinking, speaking, acting as a unit.
Presents a standardized set of 260 pictures for use in experiments investigating differences and similarities in the processing of pictures and words. The pictures are black-and-white line drawings executed according to a set of rules that provide consistency of pictorial representation. They have been standardized on 4 variables of central relevance to memory and cognitive processing: name agreement, image agreement, familiarity, and visual complexity. The intercorrelations among the 4 measures were low, suggesting that they are indices of different attributes of the pictures. The concepts were selected to provide exemplars from several widely studied semantic categories. Sources of naming variance, and mean familiarity and complexity of the exemplars, differed significantly across the set of categories investigated. The potential significance of each of the normative variables to a number of semantic and episodic memory tasks is discussed. (34 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
Article
1. Preliminaries Geoffrey K. Pullum and Rodney Huddleston 2. Syntactic overview Rodney Huddleston 3. The verb Rodney Huddleston 4. The clause, I: mainly complements Rodney Huddleston 5. Nouns and noun phrases John Payne and Rodney Huddleston 6. Adjectives and adverbs Geoffrey K. Pullum and Rodney Huddleston 7. Prepositions and preposition phrases Geoffrey K. Pullum and Rodney Huddleston 8. The clause, II: mainly adjuncts Anita Mittwoch, Rodney Huddleston and Peter Collins 9. Negation Geoffrey K. Pullum and Rodney Huddleston 10. Clause type and illocutionary force Rodney Huddleston 11. Content clauses and reported speech Rodney Huddleston 12. Relative clauses and unbounded dependencies Rodney Huddleston, Geoffrey K. Pullum and Peter G. Peterson 13. Comparative constructions Rodney Huddleston 14. Non-finite and verbless clauses Rodney Huddleston 15. Coordination and supplementation Rodney Huddleston, John Payne and Peter G. Peterson 16. Information packaging Gregory Ward, Betty Birner and Rodney Huddleston 17. Deixis and anaphora Lesley Stirling and Rodney Huddleston 18. Inflectional morphology and related matters F. R. Palmer, Rodney Huddleston and Geoffrey K. Pullum 19. Lexical word-formation Laurie Bauer and Rodney Huddleston 20. Punctuation Geoffrey Nunberg, Ted Briscoe and Rodney Huddleston Further reading Index.
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Groups of aphasic patients and their spouses generated a series of communication situations that they felt were important in their day-to-day life. Using criteria to ensure that the situations were generalizable across people, times, and places, we reduced the number of situations to 36 and constructed an index that allowed the significant others of 11 recovering and 11 stable aphasic individuals to rate their partners' performance in the situations on two occasions 6 weeks apart. These data were then used to evaluate the psychometric properties of the Communicative Effectiveness Index (CETI) as a measure of change in functional communication ability. Further application of a generalization criterion reduced the final index to 16 situations. Results- showed the CETI to be internally consistent and to have acceptable test-retest and interrater reliability. It was valid as a measure of functional communication according to the pattern of correlations found with other measures (Western Aphasia Battery, Speech Questionnaire, and global ratings). Finally, it was responsive to functionally important performance change between testings. Further research with the CETI and its usefulness for clinicians and researchers are discussed. Historically, the focus of aphasia assessment has been on language abilities with general communicative abili- ties as only a secondary consideration. Furthermore, assessment instruments have been validated with more concern for their ability to discriminate aphasic from nonaphasic performance or one aphasia type from another than for their ability to detect change in the severity of the aphasia over time. The development of an instrument with the