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Using Neuroscience to understand aphasia
recovery
UCL INSTITUTE OF NEUROLOGY
Shedding some light into the darkness!
UCL INSTITUTE OF NEUROLOGY
Who are we?Louise Lim Research Associate and Speech & Language Therapist
Johanna Rae Research Assistant (Bilingual) and Speech & Language Therapist
From:University College London, Institute of Neurology, Wellcome Trust Centre for Neuroimaging
UCL INSTITUTE OF NEUROLOGY
The patient-facing team
Prof Cathy Price
Dr Alex Leff
Louise Lim
Zula Haigh
Rachel Browne
Johanna Rae
PLORAS
UCL INSTITUTE OF NEUROLOGY
Aphasia
An acquired language disorder following brain injury.
• Affects a third of stroke survivors
• Can involve understanding language, speaking, reading and writing
• One of the most feared outcomes after stroke (Soloman, Glick, Russo, Lee and Schulman, 1994)
UCL INSTITUTE OF NEUROLOGY
Impact of Aphasia on Carers
Communication difficulties due to aphasia following stroke are particularly difficult for caregivers…
isolation
role-changeidentity
stressdepression
helplessness
UCL INSTITUTE OF NEUROLOGY
From the literature Most studies conclude that:
• Caregivers of aphasic stroke patients are more stressed, with symptoms of depression, loneliness and other emotional problems than caregivers of non-aphasic stroke patients.
• Their (carers of people with aphasia’s) overall adjustment to the stroke is poorer and they experience greater role changes.
• They have more marital difficulties with a greater number of negative attitudes toward their spouse.
(Draper at al. 2007)
UCL INSTITUTE OF NEUROLOGY
‘Not-knowing’
Recovery from aphasia is hugely variable (Hillis and Heidler, 2002)
Speech can be regained within the first few days, weeks or months after stroke or may take several years
…how can carers and patients prepare for the future?
UCL INSTITUTE OF NEUROLOGY
Impact of an unknown futureThe recovery road could be…..
Carers and patients want to be prepared for the right journey
or
UCL INSTITUTE OF NEUROLOGY
In the words of patients
“People can’t move forward until they know what’s happened to them and what the future might be”
“If you don’t know what’s happened and what the possible outcomes are it’s not possible to move forward”
With thanks to the stroke survivor presentations at the Stroke Associations UK Stroke Forum 2012
UCL INSTITUTE OF NEUROLOGY
Needs of stroke survivors and carers
• A clear understanding of what has happened
• A long term plan
• Range of possible outcomes: short and long-term
To take ownership of their recovery
UCL INSTITUTE OF NEUROLOGY
The role of the Health Professional:
The ‘tour guide’ for the journey
• What to expect – recovery outcome• Realistic short and long term goals• Support and advice
This way please…
???
UCL INSTITUTE OF NEUROLOGY
What guides Health Professionals?
• Initial severity?• Lesion size?• University?• Experience?• Research literature?• Intuition?
How confident are we that we can provide well-evidenced answers to carer’s questions about recovery?
UCL INSTITUTE OF NEUROLOGY
The tightrope for Health Professionals
False hope
High expectations
Despondency
Lack of motivation for therapy
Realistic goals & appropriate support
Depression
UCL INSTITUTE OF NEUROLOGY
Accurately predicting recovery: problem to date
Lack of understanding of how lesion site influences language outcome & recovery…
?
Years post stroke
Speaking ability
UCL INSTITUTE OF NEUROLOGY
therefore…
Predicting the recovery journey for each patient is difficult
A bit like predicting the weather in Britain based on the day before?!
UCL INSTITUTE OF NEUROLOGY
Ingredients requiredTo understand the relationship between lesion
location and language recovery we need:
• Between-patient cross-sectional comparisons for large numbers of patients
• Accurate ways of defining & comparing the lesion
• Additional within-patient longitudinal comparisons to check accuracy of predictions
UCL INSTITUTE OF NEUROLOGY
PLORAS project
Predicting Language Outcome and Recovery
After Stroke
Aim = Create a clinical tool for patients, carers and clinicians
To provide individualised predictions about recovery from aphasia after stroke, based on patient’s MRI brain image
Realistic goal-setting in therapyPlan for a return to valued activitiesAppropriate level and timing of support
UCL INSTITUTE OF NEUROLOGY
Between-patient cross-sectional comparisons for large numbers of patients
Over 500 stroke patients (and growing daily!) from
• Hospital
UCLH & NHNN
• Community
stroke groups, adverts, conferences etc
UCL INSTITUTE OF NEUROLOGY
Procedure
1.Comprehensive Aphasia Test (CAT)• Cognitive screen• Language battery• Widely used in clinical practice
2. MRI scan• Structural scan – 15 minutes
UCL INSTITUTE OF NEUROLOGY
Accurate ways of defining & comparing the lesion
High resolution 3D lesion images and advanced lesion identification software
Voxel based analysis = improved accuracy
UCL INSTITUTE OF NEUROLOGY
Meaningful interpretation of language scores
Use composite language scores e.g.
‘speech production’ score considers:
word repetition + sentence repetition + picture naming + picture description
so that visual or auditory problems alone cannot account for impairment
UCL INSTITUTE OF NEUROLOGY
Combine lesion information with language scores
For hundreds of patients…
Establish the relationship between:
• Exact lesion location • Composite language score• Time post stroke
UCL INSTITUTE OF NEUROLOGY
Understanding the lesion - behaviour relationship enables predictions for patients
UCL INSTITUTE OF NEUROLOGY
NB ‘recovery’ defined as WNL scores on Comprehensive Aphasia Test
Examples of Findings
UCL INSTITUTE OF NEUROLOGY
Key findings• Accurate relationship between lesion site and
recovery profile – tested at 98% accuracy
• Patients with speech output difficulties persisting beyond 5 years had damage that severed both anterior and posterior segments of the superior longitudinal fasciculus
UCL INSTITUTE OF NEUROLOGY
Key findings
Speech score
A
Aphasic range
A&P
Non-aphasic range
P
PLORAS
UCL INSTITUTE OF NEUROLOGY
Future work
Continually expanding patient numbers- Coming to a hospital near you (hopefully!) via the
Stroke Research Network
Adjusting predictions for clinical scans: CT/ MRI
Understanding influence of other factors- Age, motivation, amount of therapy
Functional MRI scanning with recovered patients
- To see use of alternative regions to damaged
UCL INSTITUTE OF NEUROLOGY
Discussion 1: Your experiences
Please help us by sharing your experiences of…
• What patients and carers have asked you about recovery
• What patients and carers have told you about recovery
• What kinds of answers you/others have given
• Difficulties associated with answering questions about recovery
UCL INSTITUTE OF NEUROLOGY
Discussion 2 : Your opinion
What are the implications (positive and negative) for:
• Patients• Carers• Health Professionals
Of the availability of prediction information?
What kind of information would you like to be able to give patients and carers?
How might it influence your practice?
UCL INSTITUTE OF NEUROLOGY
Discussion 3: Your advice
Giving patients recovery predictions…
• Who? e.g. therapist, doctor, support worker
• When? e.g. first week, on discharge, at home
• How? e.g. face to face, self-access
• Where? e.g. whilst in hospital, in community
• As routine? Only if asked? In worst cases?
UCL INSTITUTE OF NEUROLOGY
Taking PartWe are always recruiting patients for our research.
Inclusion criteria:• Have had a stroke.• Are able to have an MRI brain scan (we can tell you).• Are happy to have their language assessed.• Can travel to London (private transport negotiable).
We are interested in people who speak English only AND people who speak more than one language.
PLORAS
UCL INSTITUTE OF NEUROLOGY
Contact Details
• Location: 12 Queen Square, London, WC1N 3BG
• E-mail: [email protected]
• Telephone: 020 7813 1538
• Add us as a friend on Facebook: Stroke Study
• ‘Like’ our Facebook page: Aphasia Research at Wellcome Trust Centre for Neuro-imaging, UCL
• Video: http://www.wellcome.ac.uk/News/2009/Features/WTX057690.htm
• http://www.youtube.com/watch?v=Wn08mkGbGnQ
UCL INSTITUTE OF NEUROLOGY
Photograph credits
From Flickr – creative commons.
• Geodesic for ‘Road’• Rawmusic for motorway image• Girlguides of Canada for ‘Guides Book 1’• The Other Martin Taylor for ‘Tightrope Walker’• Slawek Puklo for storm image• Rhys Asplundh for ‘Sun & Clouds’• Doug 888 for ‘Richmond Snow’
UCL INSTITUTE OF NEUROLOGY
References• Brady, M., Kelly, H., Godwin, J., Enderby, P. 2012 Speech and language
therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 5.
• Draper, B., Bowring, G. Thompson, C., Van Heyst, J. Conroy, P., Thompson, J. Stress in caregivers of aphasic stroke patients: a randomised control trial. Clinical Rehabilitation, 2007 Feb; 21(2): 122-30
• Hillis, A. and Heidler, J. 2002. Mechanisms of early aphasia recovery. Aphasiology, 16(9), 885-895
• Price, C., Seghier, M., and Leff, A. 2010. Predicting language outcome and recovery after stroke: the PLORAS system. Nature Reviews Neurology 6, 202-210 .
• Seghier, M., Lee, H., Schofield, T., Ellis, C. and Price, C. 2008. Inter-subject variability in the use of two different neuronal networks for reading aloud familiar words. Neuroimage. 42(3-3): 1226–1236.
• Solomon NA, Glick HA, Russo CJ, Lee J, Schulman KA. 1994.Patient preferences for stroke outcomes, Stroke. Sep;25(9):1721-5.
• Swinburn, K., Porter, G. and Howard, D. 2004. Comprehensive Aphasia Test. Hove: Psychology Press.
UCL INSTITUTE OF NEUROLOGY
EXTRA SLIDES
Slides from here on for use if time remaining after
discussion…
UCL INSTITUTE OF NEUROLOGY
PLORAS Aim 2
To further the theoretical understanding of aphasia recovery, so that the effect of therapy
can be accurately tested
PLORAS
UCL INSTITUTE OF NEUROLOGY
Efficacy of impairment-based therapy
• Currently there are problems proving efficacy of therapy.
• Cochrane review (2012): ‒ “…insufficient evidence to indicate the best approach to
delivering speech and language therapy”. ‒ None of the 39 studies in Cochrane review accounted for lesion
site.
PLORAS
UCL INSTITUTE OF NEUROLOGY
Lesion information
We believe lesion site is critical in determining recovery and response to impairment-based therapy.
• To understand who will and will not respond to an intervention approach we first need to know:− Which brain regions are damaged?− How does damage affect language?− How does intervention influence the preserved
pathways?
PLORAS
UCL INSTITUTE OF NEUROLOGY
Future implications
• Knowledge of typical recovery trajectory• To provide a baseline against which to compare therapy• Does a given therapy speed up this typical recovery?
after intervention
predicted by lesion sp
eech
sco
re
Time post stroke
PLORAS
UCL INSTITUTE OF NEUROLOGY
Recovery pathways
Example of how the effect of damage to one pathway depends on the integrity of other pathways.
Damage to Recovery pathway
White pathway Red pathway
Red pathway White pathway
Red and white pathways
?
Seghier et al. (2008)
PLORAS