Impairment-based Approach Research Articles

Making Assessment Real: Audrey Holland's Contributions to the Assessment of Aphasia and Cognitive-Communication Disorders in Clinical and Research Settings.

For half a century, Dr. Audrey Holland investigated, developed, and implemented ways to extend the assessment of adult language and cognitive-communication disorders beyond traditional impairment-based approaches. This article summarizes Dr. Holland's many groundbreaking contributions to assessment practices by describing and exemplifying major conceptual and measurement innovations that have emerged from her research of both formal and informal assessment techniques. Dr. Holland's assessment contributions encompass the development of many widely used measures of functional communication, discourse, and cognitive-communication abilities. She also contributed to the development of assessment principles that have become part of best-practice standards of care. Some of her most significant contributions include: Drawing attention to assessment within authentic functional contexts; highlighting connections between language, communication, related cognitive abilities, and broader aspects of health including quality of life; raising psychometric standards; and emphasizing the value of implementing multiple person-centered measurement techniques spanning formal and informal as well as quantitative and qualitative approaches. Dr. Holland's career-long commitment and contributions to developing more meaningful and authentic assessment practices have transformed our field and substantively elevated the quality of care and services that we are able to provide to all persons who are impacted by language and cognitive-communication disorders.

A Comprehensive Review of Physical Therapy Interventions for Stroke Rehabilitation: Impairment-Based Approaches and Functional Goals.

Stroke is the fourth leading cause of mortality and is estimated to be one of the major reasons for long-lasting disability worldwide. There are limited studies that describe the application of physical therapy interventions to prevent disabilities in stroke survivors and promote recovery after a stroke. In this review, we have described a wide range of interventions based on impairments, activity limitations, and goals in recovery during different stages of a stroke. This article mainly focuses on stroke rehabilitation tactics, including those for sensory function impairments, motor learning programs, hemianopia and unilateral neglect, flexibility and joint integrity, strength training, hypertonicity, postural control, and gait training. We conclude that, aside from medicine, stroke rehabilitation must address specific functional limitations to allow for group activities and superior use of a hemiparetic extremity. Medical doctors are often surprised by the variety of physiotherapeutic techniques available; they are unfamiliar with the approaches of researchers such as Bobath, Coulter, and Brunnstrom, among others, as well as the scientific reasoning behind these techniques.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review.

Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address. To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke. MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases. Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low. Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Maintenance and Generalization of Lexical Items in Primary Progressive Aphasia: Reflections From the Roundtable Discussion at the 2021 Clinical Aphasiology Conference.

Our capacity to engage in society and maintain meaningful relationships is dependent on intact communication skills. They are compromised in a neurodegenerative language disorder termed primary progressive aphasia (PPA). Behavioral interventions for PPA are sparse and often limited to impairment-based approaches or communication skills training, although various functional interventions have been also described. The slow but relentless language decline does not naturally support maintenance and/or generalization of treatment gains, which should be the ultimate goal of any therapy. However, in some cases and under certain conditions, maintenance and generalization may be accomplished. While each type of intervention has much to offer to the PPA population, the clinical and research realms can benefit from a collective professional discussion on aspects of intervention conducive to maintenance and/or generalization of treatment gains in PPA. Such a discussion took place at the 2021 Clinical Aphasiology Conference during two roundtable sessions. The aims of the sessions were to review the premises of successful treatment approaches in PPA and to discuss factors fostering or inhibiting maintenance and generalization in PPA. Current literature delivers, albeit in small doses, encouraging evidence for clinicians providing language intervention to patients with PPA. Although PPA is a progressive disorder, both the immediate treatment effects and, in many cases, evidence of maintenance and generalization demonstrate that improvements may be long lasting and transferrable. Several factors may enhance maintenance and generalization effects, including repeated practice, working with multiple exemplars of treatment items, booster sessions, group programs with built-in individual sessions, spared semantics, and personal relevance, to name a few. With this evidence in hand, we need to become more diligent about measuring and reporting clinical outcomes and delivering interventions that support maintenance and generalization of therapeutic gains beyond the clinician's office. https://doi.org/10.23641/asha.19836370.

Dyadic conversation training in Mandarin for bilinguals with aphasia and their communication partners

ABSTRACT Background Treatment outcomes for functional communication, and for generalisation across languages and linguistic levels, remain mixed for bilinguals with aphasia (BWAs). Most studies on rehabilitation of BWAs report impairment-based approaches for participants with two broad similar Indo-European languages, but it remains unclear whether benefits extend to the untreated language or linguistic levels when the BWA speaks linguistically dissimilar languages. Furthermore, outcomes for communication-based approaches, where the components mirror everyday conversations and functional communication more closely, have rarely been examined in BWAs. Aim To examine the efficacy of Better Conversations with Aphasia (BCA), a dyadic communication-based treatment, in Mandarin for BWAs – direct treatment effects on conversations, impact on functional communication and emotional well-being, and generalisation both within and across languages. Methods Two Mandarin English-speaking bilingual adults with non-fluent aphasia (mild–moderate-to-severe) and their communication partner (CP) received BCA conducted in Mandarin for 1–1.5 h twice-weekly sessions over 10 weeks. The frequency of facilitators and barriers in conversation samples, questionnaires on functional communication and emotional well-being, a picture description task, and confrontation naming of nouns and verbs in both treated and untreated languages, were all assessed at baseline, post-treatment, and post-maintenance. Results Facilitators and barriers - Both BWAs and their CPs showed significant decreases in barrier-behavior frequencies, but P01 also showed a significant reduction in the use of facilitators. Functional Communication/Well-being - P01 reported positive effects for functional communication and emotional well-being, but P02 reported negative effects for both. No significant changes in the CPs’ ratings of the BWAs’ functional communication. Discourse - P01’s Mandarin narrative production showed no significant improvement but speech rate and efficiency improved for English picture descriptions. P02’s Mandarin picture descriptions contained significantly more words produced at a slower speech rate while significant gains in meaningfulness and efficiency were found in her English descriptions. Single-word - P01 showed improved confrontation naming accuracy for nouns (Mandarin only) and verbs (Mandarin and English), whereas P02 only showed significantly increased accuracy for verbs in English. Conclusions BCA treatment for two Mandarin English-speaking BWAs replicated earlier reports of positive direct treatment effects for monolingual PWAs, particularly the reduction of behaviors that hinder conversation success. Moreover, the generalisation, both within and across linguistically dissimilar languages, provides evidence for shared language networks that could be exploited by clinicians working with BWAs. The potential impact of culture, family context, linguistic structures, and cognitive deficits, on treatment outcome is also discussed.

Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke.

Rehabilitation interventions for chronic stroke are largely impairment based, with results confined to the level of impairment instead of function. In contrast, cognitive strategy training interventions have demonstrated clinically meaningful improvements in functional outcomes. Integration of these approaches has yet to be explored. To evaluate acceptability, recruitment, and retention rate and determine which outcome measures best capture the effect of the intervention. Single-group, pre-post design. Research laboratory. Adults with chronic stroke and hemiparesis (N = 10). A 12-wk intervention integrating cognitive strategy training with upper extremity motor training. Two weekly sessions used Kinect-based virtual reality to encourage high numbers of upper extremity movement repetitions. The third weekly session focused on the use of cognitive strategies with practice of client-centered goals. Upper extremity motor performance was measured with the Fugl-Meyer Assessment. Occupational performance on trained and untrained goals was measured via the Performance Quality Rating Scale and the Canadian Occupational Performance Measure. Outcome data were gathered preintervention, postintervention, and at 3-mo follow-up. The intervention was perceived as acceptable. Recruitment rate was 15%, and retention rate was 100%. Large effects were found on outcomes of upper extremity motor performance, occupational performance, and participation at follow-up. MetacogVR is feasible for adults with chronic stroke. The effect of MetacogVR is best captured through measures of upper extremity motor performance, occupational performance, and participation. Traditional, impairment-based approaches to chronic stroke rehabilitation may require integration with cognitive-strategy training to affect performance on meaningful goals.

CSD Program Makes College Possible After Brain Injury

CSD Program Makes College Possible After Brain Injury

Cost effectiveness of the occupation-based approach for subacute stroke patients: result of a randomized controlled trial

Background and purpose: The cost effectiveness of occupational therapy for subacute stroke patients is unclear in the extant literature. Consequently, this study determined the cost effectiveness of the occupation-based approach using Aid for Decision-Making in Occupation Choice (ADOC) for subacute stroke patients compared with an impairment-based approach.Methods: We conducted an economic evaluation from a societal perspective alongside a pilot randomized controlled trial, with a single blind assessor for participants in 10 subacute rehabilitation units in Japan. The intervention group received occupation-based goal setting using ADOC, with interventions focused on meaningful occupations. The control group received an impairment-based approach focused on restoring capacities. For both groups, occupational-therapy intervention was administered more than five times per week, for over 40 min each time, and they received physical and speech therapy prior to discharge. The main outcomes were quality-adjusted life years (QALYs) and total costs. Further, sensitivity analyses were performed to examine the influence of parameter uncertainty on the base case results.Results: The final number of participants was 24 in each of the two groups. In terms of QALYs, the intervention group is significantly higher than the control group (p = 0.001, difference 95% CI: 0.002–0.008) and total costs are not statistically significant. Applying a willingness-to-pay threshold of JPY 5 million/QALY, the probability of the occupation-based approach using ADOC being cost effective was estimated to be 65.3%.Conclusions: The results show that the occupation-based approach is associated with significantly improved QALYs and has potential cost effectiveness, compared with the impairment-based approach.

Effectiveness and Cost-Effectiveness of Occupation-Based Occupational Therapy Using the Aid for Decision Making in Occupation Choice (ADOC) for Older Residents: Pilot Cluster Randomized Controlled Trial.

BackgroundCare-home residents are mostly inactive, have little interaction with staff, and are dependent on staff to engage in daily occupations. We recently developed an iPad application called the Aid for Decision-making in Occupation Choice (ADOC) to promote shared decision-making in activities and occupation-based goal setting by choosing from illustrations describing daily activities. This study aimed to evaluate if interventions based on occupation-based goal setting using the ADOC could focus on meaningful activities to improve quality of life and independent activities of daily living, with greater cost-effectiveness than an impairment-based approach as well as to evaluate the feasibility of conducting a large cluster, randomized controlled trial.MethodIn this single (assessor)-blind pilot cluster randomized controlled trial, the intervention group (ADOC group) received occupational therapy based on occupation-based goal setting using the ADOC, and the interventions were focused on meaningful occupations. The control group underwent an impairment-based approach focused on restoring capacities, without goal setting tools. In both groups, the 20-minute individualized intervention sessions were conducted twice a week for 4 months.Main Outcome MeasuresShort Form-36 (SF-36) score, SF-6D utility score, quality adjusted life years (QALY), Barthel Index, and total care cost.ResultsWe randomized and analyzed 12 facilities (44 participants, 18.5% drop-out rate), with 6 facilities each allocated to the ADOC (n = 23) and control (n = 21) groups. After the 4-month intervention, the ADOC group had a significantly greater change in the BI score, with improved scores (P = 0.027, 95% CI 0.41 to 6.87, intracluster correlation coefficient = 0.14). No other outcome was significantly different. The incremental cost-effectiveness ratio, calculated using the change in BI score, was $63.1.ConclusionThe results suggest that occupational therapy using the ADOC for older residents might be effective and cost-effective. We also found that conducting an RCT in the occupational therapy setting is feasible.Trial RegistrationUMIN Clinical Trials Registry UMIN000012994

Effects of impairment-based individual and socially oriented group therapies on verb production in aphasia

Purpose: Two philosophies of intervention exist in aphasia rehabilitation: impairment-based approaches and socially oriented approaches. Both approaches have been shown to improve communication in persons with aphasia, but no studies have directly compared the effects of each approach or a combined approach on a targeted linguistic skill. This article explores the effects of individual and group therapies used both in isolation and in combination on verb production in aphasia.Methods: Twelve individuals with chronic aphasia were trained on transitive verbs under three conditions—individual, group and combined—over a 6-week interval. Treatment was counterbalanced across subject and training groups. A delayed-treatment, within-participant design was used. Verb probe data were collected at 10 points throughout the study. Language measures were taken at two intervals pre- and two intervals post-treatment. Functional, narrative and quality-of-life measures were taken once pre- and once post-treatment.Results: Significant change was observed on linguistic, functional communication and quality-of-life measures. There was no significant effect of treatment condition.Conclusions: The results provide evidence of linguistic and psychosocial change in individuals with chronic aphasia following this treatment. Results failed to find that one treatment condition was superior to others.

Comparison of occupation-based and impairment-based occupational therapy for subacute stroke: a randomized controlled feasibility study

Objective: To compare occupation-based and impairment-based approaches in occupational therapy and determine the feasibility of patient recruitment and retention. Design: A multicenter, randomized, controlled pilot trial with a single blind assessor. Setting: Ten subacute rehabilitation units in Japan. Participants: Fifty-four patients with subacute stroke. Interventions: The experimental group used the iPad application, Aid for Decision-making in Occupation Choice, to establish occupation-based goals, and evaluation and intervention were conducted mainly through real occupations. The control group was evaluated according to patients’ generic abilities and activities of daily living (ADL), and the intervention mainly involved the impairment-based approach. Main outcome measures: Short Form-36, Functional Independence Measure, Brunnstrom recovery stages, The Client Satisfaction Questionnaire, and length of hospital stay. Results: Of the 1465 potential participants, 54 (3%) subacute stroke patients were enrolled over 16 months and 68% (n = 36) were retained to the 2-month assessment: experimental group (n = 16); control group (n = 21). Although there was no significant intergroup difference for any outcomes, the experimental group had a small effect size advantage on the Short Form-36 “General health” (d = 0.42) and “Role emotional” (d = 0.43) subscales relative to the control group. A sample of 118 subacute stroke patients per group would be required for a lager study. Conclusions: Results suggest that the occupation-based approach has more potential to improve “General health” and “Role emotional” scores on the Short Form-36 than the impairment-based approach. Further investigation of study protocol with interventions and recruiting is needed prior to a larger trial.

Impairment and Functional Interventions for Aphasia: Having it All.

Aphasia, a cognitive-linguistic disorder secondary to stroke, is a frequent and often chronic consequence of stroke with detrimental effects on autonomy and health-related quality of life. Treatment of aphasia can be approached in a number of ways. Impairment-based approaches that focus on training a specific linguistic form can be implemented. Additionally, functionally oriented intervention such as supported conversation and aphasia groups are also frequently utilized when providing a treatment program for an individual with aphasia. Creating a treatment approach that includes both impairment and functional methodologies and considers how these relate to the three domains proposed by the International Classification of Functioning Disability and Health (ICF)-body functions and structure, activity, and participation-can provide an individual with aphasia an optimal treatment program that is person-centered and multi-faceted.

Recent advances in the treatment of post-stroke aphasia.

Aphasia is an impairment of language use following brain damage. There is no consensual definition of aphasia beyond this general description (Code and Petheram, 2011). In a more restricted definition, however, aphasia is an impairment of linguistic processing at the phonological, morphological, lexical semantic or syntactic level which is usually caused by lesions of the left cerebral hemisphere. This impairment can affect language reception and expression depending on the various aphasic syndromes (McNeil and Pratt, 2001). Aphasia results in restrictions in those activities of daily living which rely on communication. In terms of the International Classification of Functioning, Disability and Health (WHO, 2001), limitations in functional communication pose significant challenges to social participation (Davidson et al., 2008) and reduce the patients’ quality of life (Kauhanen et al., 1999; Shadden, 2005). Recent data on the incidence of aphasia following stroke range between 0.02 and 0.06 % with a prevalence between 0.1 and 0.4 % in the developed world (Code and Petheram, 2011). Spontaneous behavioral recovery usually occurs to some degree in the weeks to months after stroke and depends on many factors such as the infarct size and location and the severity of initial stroke deficits (Cramer, 2008). Traditionally, proposed mechanisms of the neurological intrinsic recovery are the resolution of edema surrounding the infarcted area (Katzman et al., 1977; Lo, 1986) and reperfusion of incompletely damaged, but highly vulnerable perilesional tissue (see Donnan et al., 2013). These local mechanisms are supposed to support early recovery (in days to weeks after stroke) and do not depend on behavioral experience but have been targeted by pharmacological treatments: of more than a thousand drugs tested in animal models, 114 have been studied in clinical trials (Perez de la Ossa and Davalos, 2007) and to date none of these potentially neuroprotective agents was found to be effective in humans. Only rapid reperfusion with recombinant tissue plasminogen activator (rTPA) does improve functional outcome after ischemic stroke, but its use is limited by a short therapeutic window (4.5 hours following stroke), the risk of hemorrhage and potential ischemia/reperfusion injury (Lakhan et al., 2009). In contrast, neuronal network reorganization, which also occurs spontaneously, has been related to later recovery and can be influenced by environmental and behavioral factors (Cramer, 2008; Nudo, 2011, 2013). On the molecular level, regulation of gene expression in the unaffected peri-infarct tissue seems to favour the synthesis of growth promoting and to suppress the synthesis of growth inhibiting proteins thus creating a permissive environment for axonal/dendritic sprouting and may thus offer a window of opportunity for behavioural interventions to be effective (Carmichael, 2006). Even after standard treatments provided by the health care systems, the majority of people with aphasia have a chronic communication disability. Speech and language therapy (SLT) is the current standard of care for aphasia treatment but supplemental therapeutic strategies are emerging. The aim of this short review is to give an overview of current advances in research on behavioural, pharmacological and electrophysiological treatments for post-stroke aphasia.

Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series

Study design: A case series of consecutive patients with chronic low back pain.Background and purpose: In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints.Methods: Eight consecutive patients (mean age: 43·9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC).Results: Five of the eight (62·5%) patients reported ‘moderately better’ or higher (>+4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24·4% reduction in ODI scores.Discussion: This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.

“Natural” conversation: A treatment for severe aphasia

Background: Many treatment approaches based on different concepts of aphasia have been proposed. Nowadays two main approaches face each other: the impairment- and the consequences-based approaches. The impairment-based approach draws directly from cognitive neuropsychology and is aimed at improving the linguistic deficit. The consequences-based approach (or functional or psychosocial approach) has its roots in the pragmatic approach and endeavours to reduce the consequences of aphasia in daily living. Aims: The aim of this study is to present a treatment for severe aphasia that partially reconciles the two approaches. It incorporates some principles of the impairment-based approach and utilises them in a “natural” situation that has a direct impact on the daily life of patients with aphasia. Methods & Procedures: The description of the characteristic of a conversation between two normal interlocutors serves to illustrate how a theory of conversation can help guide the clinician's behaviour during “natural” conversation/rehabilitation with a severely aphasic patient. Application of the conversation/rehabilitation treatment is illustrated by the case of Mr I, a global aphasic patient 18 months post-onset who underwent 9 months of treatment. Outcomes & Results: Positive outcome was obtained. Mr I was initially unable to keep in contact with anybody or even understand that others were trying to interact with him. After treatment, his approach to others had substantially changed. He showed interest in what happened around him and was capable of sustaining a conversation if his interlocutors took some simple measures to facilitate his comprehension. Conclusions: The conversation/rehabilitation treatment partly reconciles the impairment- and consequences-based approaches and this study demonstrates that at least for one man with aphasia, Mr I, the treatment was successful.

A comparison of functional and impairment-based robotic training in severe to moderate chronic stroke: A pilot study

To compare the outcome of training the functional movement of transport of the arm and grasping an object with the alternative of training the transport of the arm in isolation. Pretest-posttest comparison. Rehabilitation hospitals, outpatient care. Volunteer sample of forty-seven persons with persistent hemiparesis from a single, unilateral stroke within the past one to five years. Robotic therapy 3 x/week for 6 weeks for the paretic upper limb consisted of either a) sensorimotor, active-assistive impairment-based exercise during repetitive planar reaching tasks, or b) a "free-hand" approach, in which the robot assisted subjects employing the sensorimotor active-assistive exercise to transport the hand to a series of targets, where it stopped to allow the person to interact with actual objects (functional approach 1), or c) transport and manipulation, in which the robot assisted subjects employing active-assistive exercise during repetitive planar reaching tasks while grasping a simulated object and releasing it at the target or followed by grasp and release of a simulated object (functional approach 2). Fugl-Meyer Assessment. All three groups improved from pre- to post-treatment with the sensorimotor impairment based approach demonstrating the best outcome of the three approaches. Short-term, goal-directed robotic therapy can significantly improve motor abilities of the exercised limb segments in persons with chronic stroke, but contrary to expectation, training both the transport of the arm and manipulation of an object (functionally-based approaches) did not confer any advantage over training solely transport of the arm (impairment-based approach).