LET'S TALK: UPDATE ON APHASIA TREATMENT

DISCLOSURE

Leora R. Cherney, PhD Professor, Physical Medicine & Rehabilitation, Northwestern University;

Director, Center for Aphasia Research & Treatment, Rehabilitation Institute of

Chicago

• Receives salary from the Rehabilitation Institute of Chicago

• Is funded by grants from the NIH and NIDRR

• Receives an honorarium from AAPM&R for this presentation

LET'S TALK: UPDATE ON APHASIA TREATMENT

Current research in aphasia interventions has added to the understanding of how newer practices address recovery of communication abilities following stroke. This course will review the evidence for high-intensity speech language pathology interventions for aphasia, including oral reading for language in aphasia, scripts, and constraint programs. The current state of transcranial brain stimulation will also be discussed and new technologies to enhance communication abilities will be outlined.

Learning Objectives:

• Describe the evidence for the impact of medication and transcutaneous cortical stimulation on enhancing communication in adults with aphasia;

• Recommend the appropriate intensity, duration, and type of exercise in adults with new and/or chronic aphasia;

• Provide appropriate referrals for devices to enhance communication for patients with aphasia.

LET'S TALK: UPDATE ON APHASIA TREATMENT

Current research in aphasia interventions has added to the understanding of how newer practices address recovery of communication abilities following stroke. This course will review the evidence for high-intensity speech language pathology interventions for aphasia, including oral reading for language in aphasia, scripts, and constraint programs. The current state of transcranial brain stimulation will also be discussed and new technologies to enhance communication abilities will be outlined.

Learning Objectives:

• Describe the evidence for the impact of medication and transcutaneous cortical stimulation on enhancing communication in adults with aphasia;

• Discuss the appropriate intensity, duration, and type of exercise in adults with new and/or chronic aphasia;

• Provide appropriate referrals for devices to enhance communication for patients with aphasia.

PRINCIPLES OF EXPERIENCE-DEPENDENT

NEURAL PLASTICITY

Kleim & Jones, 2008

WHAT IS “TREATMENT INTENSITY”?

Warren, Fey, and Yoder (2007) and Baker (2012)

• Dose form i.e. the typical task or activity within which the teaching episodes are delivered

• Dose , i.e., # teaching episodes (unique combination of “active ingredients”) per session; number of therapeutic inputs or client acts per session (e.g. 100 trials)

• Session duration (e.g. 60 minutes)

• Session frequency (e.g. 3x per week)

• Total intervention duration (e.g. 12 weeks)

Cumulative Intervention Intensity (CII)

• dose x dose frequency x total intervention duration

• 100 trials X 3x a week X 12 weeks = 3600 productions of target

HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF A

CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN JOURNAL

OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.

HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF

A CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN

JOURNAL OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.

HARNISH, S. M., MORGAN, J., LUNDINE, J. P. ET AL. (2014). DOSING OF A

CUED PICTURE-NAMING TREATMENT FOR ANOMIA. AMERICAN JOURNAL

OF SPEECH LANGUAGE PATHOLOGY, 23, S285-299.

HOW DO OUR APHASIA STUDIES MEASURE

UP TO THIS FORMULA?

Aphasia studies that directly compared conditions of higher

and lower intensity treatment for aphasia

Identified by 25 expanded terms used to search 15 electronic

data bases and specific journals related to aphasia

12 studies (N=225) • 1990-2006: 6 studies (Cherney et al., 2008)

• 2007-2011: 5 studies (Cherney et al., 2010, 2011)

• 2012-2014: 1 study (N=30) (Martins et al., 2013)

Dose reporting (Cherney, 2012) • 3/12 studies reported dose – so CII could only be calculated on 3/12 studies

• 8/12 studies reported: Session duration

• 9/12 studies also reported: Total # sessions

WHAT DOES THE LITERATURE TELL US

ABOUT APHASIA TREATMENT INTENSITY?

Considerations

• Acute/subacute vs Chronic aphasia

• Outcomes (WHO ICF levels)

Impairment

Activity/participation

ACUTE/SUBACUTE APHASIA

Results

Study Intensive Non-Intensive Equivocal

Impairment Bakheit et al.,

(2007) + Denes et al.,

(1996) + Martins et al.,

(2013) + Activity/

Participation

Martins et al.,

(2013) +

ACUTE APHASIA AND TREATMENT INTENSITY

Bakheit, A. M. O., Shaw, S., Barrett, L. et al. (2007). A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clinical Rehabilitation, 21, 885-894.

N=116; mean TPO = 34.2 days (intensive); 28.1 days (non-intensive)

Allocated to 5 hrs/wk and 2 hrs/wk for 12 weeks

Received 35.6 (16.4) hrs over 37.6 (14.9) sessions vs 19.3 (6.4) hrs over 19.3 (5.1 sessions)

No treatment effect of intensive therapy; contrasts with Denes et al. 1996

Amount of speech and language therapy received by intensive group was below the threshold required to significantly enhance language function; many patients were not able to tolerate more than 2 hrs/week of SLT in the first few weeks after stroke

SUBACUTE APHASIA AND TREATMENT INTENSITY MARTINS, I. P., LEAL, G., FONSECA, I., ET AL. (2013). A RANDOMIZED, RATER-BLINDED,

PARALLEL TRIAL OF INTENSIVE SPEECH THERAPY IN SUB-ACUTE POST-STROKE APHASIA: THE

SP-I-R-IT STUDY. INT J LANG COMMUN DISORD, 48, 421-431.

N=30; mean TPO = 7.67 weeks (intensive); 7.47 weeks (non-intensive)

Allocated to 2 hrs/day, 5 days/week for 10 weeks (Intensive) and 2 hrs/week for 50 weeks (Regular)

Primary outcome: Proportion of responders in each treatment group. Responder: Increase of at least 15 AQ points from baseline at 50 weeks

Trend for greater improvement in language and functional communication measures with Intensive compared to Regular treatment.

CHRONIC APHASIA

Study (N) Intensive Non-Intensive Equivocal

Impairment Basso & Caporali (2001)

(N=6) +

Harnish et al., (2008)

(N=1) +

Hinckley & Craig (1998)

(N=10) +

Pulvermuller et al., (2001)

(N=17) +

Ramsberger & Marie (2007)

(N=4) +

Raymer et al. (2006)

(N=5) +

Sage et al. (2011)

(N=8) +

Activity/

Participation

Hinckley & Carr (2005)

(N=13) +

Lee et al. (2009)

(N=17) +

COMMENTS: OPTIMUM DOSING?

Complex inter-relationship between treatment intensity and improvement

Consider, for e.g.: • Participant characteristics (WHO)

Severity of aphasia Time post stroke

• Treatment characteristics Treatment targets (WHAT)

Specificity Complexity

Type of Treatment (HOW) Error-free vs error-less Part vs whole

• Treatment scheduling (WHEN) Session length Treatment duration Timing of treatment (time of day)

Perhaps there is a threshold that must be reached in order to make long-lasting improvements

BEST (POSSIBLE/AVAILABLE) CURRENT SCIENTIFIC

EVIDENCE – CHRONIC APHASIA

Allen et al. (2012). TSR;19:523-535

• Search yielded 744 studies; 21 met inclusion criteria (RCT)

• 15 distinct interventions that fell into 5 treatment categories:

Constraint induced aphasia therapy

Language and communication therapies

Technological interventions

Pharmacotherapies

Brain stimulation techniques

A PARADIGM FOR LANGUAGE ACTION THERAPY

Difrancesco S, Pulvermuller F, Mohr

B. Intensive language-action therapy

(ILAT): The methods. (2012)

Aphasiology, 26, 1317-1351.

PRINCIPLES OF CILT

Forced verbal language use

• Verbalization required; Compensatory strategies prohibited

Intensive treatment schedule • 3 hrs/day 5 days/week 2 weeks • Massed practice

Shaping verbal responses • Begin with words or short phrases • Move to longer and more complex utterances • Barrier games • Go Fish–like activity: pictures selected for individual participants;

response components predetermined

Initial publication: Pulvermuller et al. (2001) Constraint-Induced Therapy of chronic aphasia after stroke. Stroke, 32, 1621-1626.

CILT TREATMENT (Maher et al., 2006)

Materials: Pairs of cards Level 1: Single words

• Request: Speaker communicates: book • Response: Receiver communicates: yes + book; no + book

Level 2: Carrier phrase + noun • Request: Speaker communicates: Bill, do you have a book ? • Response: Receiver communicates: Yes, Patrick, I have a book; No,

Patrick, I do not have a book

Level 3: Carrier phrase + adjective + noun • Request: Speaker communicates: Bill, do you have a red book ? • Response: Receiver communicates: Yes, Patrick, I have a red book; No,

Patrick, I do not have a red book

Level 4: Carrier phrase + # + adjective + noun • Request: Speaker communicates: Bill, do you have three red books ? • Response: Receiver communicates: Yes, Patrick, I have three red books;

No, Patrick, I do not have three red books

CONSTRAINT INDUCED LANGUAGE

THERAPY (CILT)

Pulvermuller et al., 2001

• RCT

• CILT: communicate only verbally; all compensatory

strategies suppressed; average of 31.5 hrs of Rx over

2 weeks

• Traditional therapy: average of 33.9 hours over 3-5

weeks

• CILT group improved significantly on AAT and a

Communicative Activity Log (CAL)

• Are improvements due to type of Rx or intensity of Rx?

Overall language profile scores calculated as the average of results from 4 clinical tests

revealed significant improvement in the CI aphasia therapy group but not in the control group

receiving conventional aphasia therapy.

Pulvermüller F et al. Stroke. 2001;32:1621-1626

Copyright © American Heart Association, Inc. All rights reserved.

CONSTRAINT INDUCED LANGUAGE THERAPY (CILT)

MODIFICATIONS/INDIVIDUALIZATION

Topics relevant to particular patient

• Easy to get images from google images

Level relevant to particular patient

• Flexible so not too hard or too easy

Language structures/Speech acts addressed:

• Requests / Commands / Statements

• Single words / noun phrase / S-V-O sentence

• Verbs (past/present)

Production and/or Comprehension task

Target: phonology/semantics/ syntax

Play videos

WHAT DOES THE LITERATURE TELL US

ABOUT CILT?

Cherney, L. R., Patterson, J. P., Raymer, A. et al. (2008). Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282-1299.

Update, 2010.

http://www.asha.org/uploadedFiles/EBSR-Updated-CILT.pdf

CILT SUMMARY

18 studies with 202 participants

Language impairment measures

Acute aphasia: One study; improvement shown

Chronic aphasia: 11 exploratory studies with mixed results

2 efficacy studies reported significant change

Most participants had nonfluent aphasia Communication activity/participation measures Acute aphasia: One study; change on treatment task

Chronic aphasia: Results generally favor CILT

Varying tasks and response targets

Evolution of constraints: relatives as clinicians; dosage;

pharmacotherapy; RH activation; syntax module; activities • Maintenance of CILT effects: Equivocal evidence

ORAL READING FOR LANGUAGE IN APHASIA (ORLATM)

Sentences and paragraphs repeatedly read aloud, first in

unison with the clinician and then independently

Key Element: • Theoretical basis

• Oral reading is systematically applied

• Focuses on connected discourse

• Permits modeling of more natural speech

• Allows practice on a variety of grammatical structures

• Graded levels based on stimuli length and reading level

• Consistent with Principles of Learning Theory Active participation by the learner

Repetitive practice in the overlearning of skills

Use of meaningful materials that are graded in difficulty

ORLATM PARTICIPANT

Play videos

ORLATM – SCREEN SHOTS

ORLA: ASSESSING TREATMENT INTENSITY

(FROM CENTER FOR APHASIA RESEARCH AND TREATMENT,

REHABILITATION INSTITUTE OF CHICAGO; NIDRR - H133G040269)

Randomized Single-Blind Intent-to-Treat Study of Chronic Nonfluent Aphasia • Comparing high-intensity (10 hours per week) and

low-intensity (4 hours per week) aphasia treatment Using as a treatment platform a computer version of Oral

Reading for Language in Aphasia (C-ORLA)

A Matched No-Treatment Control Group (historical) • Comparing high-intensity (10 hours per week) and

low-intensity (4 hours per week) C-ORLA to no-treatment

STUDY DESIGN

Pre-Treatment Assessment

Randomization

Post-treatment Assessment

High Intensity

Language Tx

No Tx Matched

Controls

Low Intensity

Language Tx

Interim Testing

Non-fluent

aphasia

4 hrs/week 10 hrs/wk Control

Group

# Subjects 12 10 25

Males:

Females

9:3 5:5 16:9

Age 55.57 (15.06)

31.35-77.98

56.54 (13.97)

25.83-74.50

58.2 (12.0)

35.18-79.64

Months

post onset

50.70 (45.84)

7.3-159.8

37.84 (26.26)

7.6-77.3

54.0 (59.30)

12.2-253

Baseline

WAB AQ

48.76 (22.18)

13.7-77.1

49.59 (19.37)

28.0-78.9

53.74 (25.34)

9.7-81.4

Mean Change in WAB AQ Scores from Pre- to Post-Treatment

-1

0

1

2

3

4

5

6

7

8

Me

an

Ch

an

ge

in

WA

B A

Q

Series1 5.21 -0.36 3.92 6.76

C-ORLA - All Subjects No Tx Controls 4 hour 10 hour

Mean Change in WAB AQ from PreTreatment

0

1

2

3

4

5

6

7

8

Mean

ch

an

ge in

WA

B A

Q

Series1 3.92 1.66 6.76

4 Hour Group: Post Tx 10 Hour Group: Interim 10 Hour Group: Post Tx

INDIVIDUAL SUBJECT DATA

C-ORLA 4-Hour Treatment Group

Pre- and Post-Treatment WAB Score

0

10

20

30

40

50

60

70

80

90

Subjects

WA

B A

Q S

co

re

Pre-Tx

Post Tx

Pre-Tx 13.7 19.2 26.6 36.3 39.9 43.1 53.8 61 67.4 72.9 74.1 77.1

Post Tx 10.3 21.4 29.3 34 43 58.6 65.3 57.6 77.4 81.7 73.4 80.1

1 2 3 4 5 6 7 8 9 10 11 12

C-ORLA 10-hour Treatment Group

Pre- , Interim and Post-Treatment WAB Scores

0

10

20

30

40

50

60

70

80

90

Subjects

WA

B A

Q S

co

re

PreTx

Interim

Post Tx

PreTx 28 29.8 31.8 34.1 37.1 56 62.7 68.1 69.4 78.9

Interim 30.4 35.2 39.5 27.3 37.2 53.7 72.2 66.8 72.3 77.9

Post Tx 33.2 46.8 54 34.4 45.6 62.4 69.9 68.1 71.6 77.5

1 2 3 4 5 6 7 8 9 10

CONCLUSIONS – IS MORE BETTER?

C-ORLA may be an efficacious treatment for people with chronic nonfluent aphasia

Over a 6-week period, there was a trend for greater language improvement with increased intensity and amount of therapy

After 24 treatment sessions, there was a trend towards greater improvement when sessions scheduled less intensively

There may be a critical amount and intensity of treatment needed for maximum improvement; depending on the nature of the treatment (as well as subject characteristics, outcome measures) different intensities of treatment may be preferable at different times during the learning process (acquisition vs retention and transfer)

Adequate power ?

APHASIA SCRIPTS: TRAINING SEQUENCE

1. Listening/reading whole conversation

2. Single sentence practice

• Self-monitoring

• Individual word practice

3. Conversation practice

• Options to remove cues (face, voice, written words)

QUESTION 1:

Does amount of treatment correlate

with amount of improvement on

conversational script measures

• Content (number of script related words)

• Rate (script related words per minute)

RESEARCH PROTOCOL

Three personalized scripts are developed for each subject

Each script is practiced for three weeks (total of 9 weeks of treatment)

Scripts are practiced daily at home for at least 30 minutes on a loaned laptop

Once-weekly sessions with SLP to check status and ensure compliance

Script training facilitated by state of the art software program

PARTICIPANTS

(8 MALES; 9 FEMALES)

Age Time post

stroke

(months)

WAB AQ

Mean 53.3 65.8 65.1

Std

Deviation

12.7 67 15.3

Range 31-70 10.6 –

272.7

30.5 – 85.3

PARTICIPANT TREATMENT TIME (N=16; REMOVAL OF OUTLIER WITH 151.85 TOTAL HRS; 16.8 HRS/WK

Total Hours

over 9 weeks

Mean hours per

week

Mean 40.32 4.48

Std. Deviation 15.11 1.68

Range

17.40 - 68.61 1.93 - 7.62

CORRELATIONS BETWEEN TREATMENT HOURS

AND OUTCOMES (% CHANGE)

Content (number of script related words)

• Mean change = 45.72% (SD=57.59)

• r=.67, p<.01

Rate (script related words per minute)

• Mean change = 137.48% (SD=109.53)

• r=.53, p<.05

THE INTENSIVE COMPREHENSIVE APHASIA

PROGRAM (ICAP): DEFINITION

High Intensity

• ≥ 3 hrs/day

• 4-5 days/wk

• ≥ 2 weeks

Combination of

approaches

• Individual

• Group

• Technology

Targets all areas of ICF

• Impairment

• Activity

• Participation

Patient & Family Education

Cohort of participants

• Starts and ends at same

time

Cherney et al., 2011; Rose, Cherney, & Worrall, 2013

9/2/11

2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

LIVING WITH APHASIA: FRAMEWORK FOR

OUTCOME MEASUREMENT (A-FROM)

INTERNATIONAL SURVEY RESULTS (ROSE,

CHERNEY & WORRAL, 2013)

Number and distribution of hours

Staffing

Family Involvement

Admission Criteria

Factors that contribute to ICAP success

INTERNATIONAL SURVEY RESULTS - NUMBERS

Years in

Operation

Times

offered per

year

Number of

PWA per

year

Number of

hours of

service

Hours per

day

Avg 4.6

Range (1-20)

Avg 3.13

Range (1-12)

Avg 17.3

Range (3-60)

Avg 101

Range (48-

150)

Avg 4.75

Range (3-7)

12 ICAPs reporting:

INTERNATIONAL SURVEY RESULTS - NUMBERS

Years in

Operation

Times

offered per

year

Number of

people per

year

Number of

hours of

service

Hours per

day

Avg 4.6

Range (1-20)

Avg 3.13

Range (1-12)

Avg 17.3

Range (3-60)

Avg 101

Range (48-

150)

Avg 4.75

Range (3-7)

RIC ICAP

6 YEARS 2 TIMES 20 120 HOURS 6 HRS/DAY

12 ICAPs reporting:

RIC’S INTENSIVE COMPREHENSIVE

APHASIA PROGRAM

What is a day like?

• 2 hours of Individual Treatment

• 1 hour CILT

• 1 hour Reading/Writing session

• 1 hour computer session

• 1 hour conversation group

RIC Intensive Aphasia Program Week 2 April 29 – May 3

Period Monday Tuesday Wednesday Thursday Friday

9.00

Constraint

Therapy

(Room 22)

Constraint

Therapy

Constraint

Therapy

Constraint

Therapy

Constraint

Therapy

10.00

Individual

Therapy

Individual

Therapy

Individual

Therapy

Individual

Therapy

Individual

Therapy

11.00

Reading /

Writing Group

Reading /

Writing Group

Reading /

Writing Group

Reading /

Writing Group

Reading /

Writing Group

12.00

Lunch

Lunch

Lunch

Lunch

Lunch

1.00

Computers

Computers

Computers

Computers

Computers

2.00

Individual

Therapy

Individual

Therapy

Individual

Therapy

Individual

Therapy

Individual

Therapy

3.00

Conversation

Group

(computer lab)

Conversation

Group

Conversation

Group

Conversation

Group

Conversation

Group

4.00

Music Therapy

Rm. 850

5:00 p.m.

Dinner

(optional)

Music Therapy

Rm. 850

FIRST TIME PARTICIPANTS

PRELIMINARY PAIRED T-TEST: LANGUAGE MEASURES

WAB AQ (100)

WAB LQ (100)

WAB CQ (100)

BNT (60)

Mean Pre (SD)

Mean Post (SD)

49 (24)

56 (23)

52 (19)

60 (18)

60 (18)

66 (18)

17 (20)

21 (21)

Difference +7 +8 +6 +4

p value <.001* <.001* <.001* <.001*

N= 63 60 38 58

Babbitt, Worrall &

Cherney (2014)

PRELIMINARY PAIRED T-TEST:

PARTICIPATION MEASURES

REPORTEDOUTCOMES CETI

PWA (100)

CETI

Caregiver

ASHA-QCL (80)

CCRSA (40)

Mean Pre (SD)

Mean Post (SD)

55 (18)

64 (18)

47 (17)

58 (16)

58 (11)

62 (11)

27 (6)

30 (6)

Difference +9 +11 +4 +3

p value <.001* <.001* <.001* <.001*

N= 61 60 62 59

CETI CG difference score > 11.4

Lomas et al 1989

Persad, Wozniak & Kostopoulos. 2013

UMAP – 54 first-time PWA from 1999 – 2010

• Majority of PWA (42/54) showed clinically significant improvement

on objective language impairment measures

InterACT – 71 first-time PWA from 2002 – 2012

• Majority of PWA (45/71) showed clinically significant improvement

on objective language impairment measures

• About 50% PWA showed clinically significant improvement in

functional communication

• Fewer than 5% did not make a clinically significant change on any

measure (WAB, CADL, CETI)

Age, gender and TPO were not predictive of therapy outcome.

SELECTED REFERENCES - CILT

Cherney, L.R., Patterson, J., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals with Stroke-Induced Aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282-1299.

Cherney, L.R., Patterson, J., Raymer, A., Frymark, T., & Schooling, T. (2010). Updated Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia. Available at: http://www.asha.org/uploadedFiles/EBSR-Updated-CILT.pdf

Difrancesco S, Pulvermuller F, Mohr B. Intensive language-action therapy (ILAT): The methods. (2012) Aphasiology, 26, 1317-1351.

Faroqi-Shah, Y. & Virion, C. R. (2009). Constraint-induced language therapy for agrammatism: Role of grammaticality constraints. Aphasiology, 23, 977 – 988.

Goral, M. & Kempler, D. (2009). Training verb production in communicative context: Evidence from a person with chronic non-fluent Aphasia. Aphasiology. 23(12), 1383–1397.

Kurland, J., Pulvermuller, F., Silva, N., Burke, K., & Andrianopoulos, M. (2012). Constrained vs unconstrained intensive language therapy in two individuals with chronic, moderate-to-severe aphasia and apraxia of speech: Behavioral and fMRI outcomes. American Journal of Speech-Language Pathology, 21, S65-S87.

Kirmess, M., & Maher, L. (2010). Constraint induced language therapy in early aphasia rehabilitation. Aphasiology, 24, 725–736.

Maher, L.M., Kendall, D., Swearengin, J.A., Rodriguez, A., Leon, S.A., Pingel, K., Holland, A., & Rothi, L.J.G. (2006). A pilot study of use-dependent learning in the context of constraint induced language therapy. Journal of the International Neuropsychological Society, 12, 843-852.

Meinzer, M., Djundja, D., Barthel, G., Elbert, T., Rockstroh, B. (2005). Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36, 1462-1466.

Meinzer, M., Elbert, T., Wienbruch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20. Retrieved from: www.biomedcentral.com/1741-7007/2/20.

Meinzer, M., Rodriguez, A. D., Gonzalez Rothi, L. J.. (2012). First decade of research on constrained-induced treatment approaches for aphasia rehabilitation. Arch Phys Med Rehabil, 93(1 Suppl 1), S35-45.

Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, Br., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621-1626.

Pulvermuller, F., Hauk, O., Zohsel, K., Neininger, B., & Mohr, B. (2005). Therapy-related reorganization of language in both hemispheres of patients with chronic aphasia. NeuroImage, 28, 481-489.

REFERENCES - ORLA

Cherney, L. R. (2010). Oral Reading for Language in Aphasia (ORLA): Impact of aphasia severity on cross-modal outcomes in chronic nonfluent aphasia. Seminars in Speech-Language Pathology, 31, 42-51.

Cherney, L. R. (2010). Oral Reading for Language in Aphasia (ORLA): Evaluating the Efficacy of Computer-Delivered Therapy in Chronic Nonfluent Aphasia. Topics in Stroke Rehabilitation, 17(6), 423-431.

Cherney, L. R., Kaye, R. C., & Hitch, R.S . (2011). The best of both worlds: Combining synchronous and asynchronous telepractice in the treatment of aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 21(3), 83-93.

Cherney, L., Merbitz, C. and Grip, J. (1986). Efficacy of oral reading in aphasia treatment outcome. Rehabilitation Literature, 112-119.

Cherney, L. R. (1995). Efficacy of oral reading in the treatment of two patients with chronic Broca's aphasia. Topics in Stroke Rehabilitation, 2(1), 57-67.

Cherney, L. R., Babbitt, E. M., & Oldani, J. (2004). Cross-Modal Improvements During Choral Reading: Case Studies. Presented at the Clinical Aphasiology Conference, Park City, Utah, May, 2004.

Cherney, L. R. (2004). Aphasia, Alexia, and Oral Reading. Topics in Stroke Rehabilitation, 11(1), 22-36

REFERENCES - SCRIPTING

Bilda, K. (2011). Video-based conversational script training for aphasia: A therapy study. Aphasiology, 25, 191 – 201.

Cherney, L. R. & Halper, A. S. (2008). Novel Technology for Treating Individuals with Aphasia and Concomitant Cognitive Deficits. Topics in Stroke Rehabilitation, 15(6), 542-554.

Cherney, L. R., Halper, A. S., Holland, A. L., & Cole, R. (2008). Computerized script training for aphasia: preliminary results. American Journal of Speech-Language Pathology, 17, 19-34.

Cherney, L. R., Halper, A. S., Holland, A. L., Lee, J. B., Babbitt, E., & Cole, R. (2007). Improving conversational script production in aphasia with virtual therapist computer treatment software. Brain and Language, 103, 246-247.

Cherney, L. R., Halper, A. S., & Kaye, R. C. (2011). Computer-based script training for aphasia: Emerging themes from post-treatment interviews. Journal of Communication Disorders, 44, 493–501.

Cherney, L. R., Kaye, R. C., & Van Vuuren, S. (2014). Acquisition and maintenance of scripts in aphasia: A comparison of two cuing conditions. American Journal of Speech Language Pathology. 23, S343-S360.

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