Combining rTMS With Intensive Language-Action Therapy in Chronic Aphasia: A Randomized Controlled Trial.

Paula H Heikkinen,Antti Ahvenainen,Friedemann Pulvermüller,Jyrki P Mäkelä,Risto J Ilmoniemi,Anu Klippi,Riitta-Leena Manninen,Pantelis Lioumis,Teija Kujala

doi:10.3389/fnins.2018.01036

Abstract

Neuromodulation technologies, such as transcranial magnetic stimulation (TMS), are promising tools for neurorehabilitation, aphasia therapy included, but not yet in common clinical use. Combined with behavioral techniques, in particular treatment-efficient Intensive Language-Action Therapy (ILAT, previously CIAT or CILT), TMS could substantially amplify the beneficial effect of such behavioral therapy alone (Thiel et al., 2013; Martin et al., 2014; Mendoza et al., 2016; Kapoor, 2017). In this randomized study of 17 subjects with post-stroke aphasia in the chronic stage, we studied the combined effect of ILAT and 1-Hz placebo-controlled navigated repetitive TMS (rTMS) to the right-hemispheric inferior frontal cortex—that is, to the anterior part of the non-dominant hemisphere's homolog Broca's area (pars triangularis). Patients were randomized to groups A and B. Patients in group A received a 2-week period of rTMS during naming training where they named pictures displayed on the screen once every 10 s, followed by 2 weeks of rTMS and naming combined with ILAT. Patients in group B received the same behavioral therapy but TMS was replaced by sham stimulation. The primary outcome measures for changes in language performance were the Western Aphasia Battery's aphasia quotient AQ; the secondary outcome measures were the Boston naming test (BNT) and the Action naming test (Action BNT, ANT). All subjects completed the study. At baseline, no statistically significant group differences were discovered for age, post-stroke time or diagnosis. ILAT was associated with significant improvement across groups, as documented by both primary and secondary outcome measures. No significant effect of rTMS could be documented. Our results agree with previous results proving ILAT's ability to improve language in patients with chronic aphasia. In contrast with earlier claims, however, a beneficial effect of rTMS in chronic post-stroke aphasia rehabilitation was not detected in this study.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03629665

Highlights

Language involves a complex neuronal network distributed across the brain
In particular treatment-efficient Intensive Language-Action Therapy (ILAT, previously CIAT or CILT), transcranial magnetic stimulation (TMS) could substantially amplify the beneficial effect of such behavioral therapy alone (Thiel et al, 2013; Martin et al, 2014; Mendoza et al, 2016; Kapoor, 2017). In this randomized study of 17 subjects with post-stroke aphasia in the chronic stage, we studied the combined effect of ILAT and 1-Hz placebo-controlled navigated repetitive TMS to the right-hemispheric inferior frontal cortex—that is, to the anterior part of the non-dominant hemisphere’s homolog Broca’s area
With the present randomized controlled trial (RCT), we aimed at finding an optimal protocol for the neurorehabilitation of chronic post-stroke aphasia by combining two promising methods, ILAT (Intensive language action therapy) and 1-Hz repetitive TMS (rTMS) to the righthemispheric homolog of the anterior language area of Broca, taking advantage of recent research in speech and language sciences, neurorehabilitation and brain research

Summary

Introduction

Language involves a complex neuronal network distributed across the brain. There is a general consensus on the dominance of the left hemisphere for most elements of language processing (Somers et al, 2015). The right hemisphere contributes in expressive and receptive language (Kertesz, 1985). Lesions of the left hemisphere disturb language functions more severely than those of the right one (Pedersen et al, 1995). Hemispheric transfer of linguistic functions to the non-dominant side may be one of the mechanisms of recovery in aphasia (Pulvermüller and Schönle, 1993; Saur et al, 2006; Saur and Hartwigsen, 2012; Turkeltaub, 2015). In a different perspective, the right non-dominant hemisphere is seen as a hindrance rather than a supplement of language recovery. One strategy of language therapy has aimed at inhibiting these right-hemisphere homologs. The anterior part of the right hemisphere’s Broca’s homolog area (BA 45) has been investigated intensively; previous work indicates that inhibitory repetitive TMS to this site may improve the outcome of aphasia rehabilitation (Turkeltaub, 2015)

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Results

Conclusion