This is a transcript of the interview by Edward Taub and Gitendra Uswatte, who are researching constraint-induced aphasia therapy.. The audio version of the interview can be found at approximately 35 minutes into Episode 2 (5/2) of the podcast.
Chandru Vittalbabu (host): Can you tell me a little bit about the VAL?
Edward Taub: It’s a structured interview that compares the current amount and quality of spoken language in a variety of behaviorally distinct, real-life situations, with these characteristics prior to disease onset. The key phrase is that it is a behaviorally based instrument so that it was designed to evaluate the effects of CI aphasia therapy 2, which is a behaviorally based intervention. And the VAL is a design to evaluate the effects, the behavioral effects of a behavioral intervention. Obviously behavioral intervention with respect to language, but spoken language. And it does not tap into uh other forms of communication. Like gestural or facial grimaces or pointing. Any compensatory means of communication is excluded.
Gitendra Uswatte: The motivation for this kind of measure that focuses on amount of speech in everyday life outside of the treatment setting um derived from work that ended with the deactivated monkeys some time back.
ET: The monkeys don’t talk (laughs)
GU: Yes so-
ET: They communicate.
GU: It relates to the idea of learned non-useThis work was first done in monkeys with the deactivated forelimb and applied to stroke patients with upper extremity hemiparesis. And in the patients with upper extremity hemiparesis, what we found is in many cases there is a substantial difference between how much and how well they use their more affected arm in the everyday setting and what they do when you ask them to use that arm in the lab. So often patients will use that arm when you ask them to in the lab setting, but then if you question them about what they’re doing at home, they’re using that arm very little or not at all. And you have a parallel phenomenon in people with aphasia where they in a lab test may be able to produce speech but um if you question them or examine how much they’re speaking at home, they’re speaking very little.
ET: And one other consideration that should be made about the VAL is that in the paper that we published about it, we also validated or studied another measure, which is an audio recording, which was an objective audio recording of the speech that people produce in the life situation based on recordings made from a recorder worn in a person’s clothing. We take a random sample or a random sample of segments of speech during an extended period of time. Over the course of a day, or it could be two days, and we’ve compared the results in the VAL which is a structured interview. It is answered jointly, or it could be answered by a patient and confirmed by a caregiver. And we’ve compared that to the results for the audio recording. And they’re very highly correlated.
CV: Do you feel that the recorder accurately captured patients’ conversations?
GU: Our experience is that when you record continuously like that, people get accustomed very quickly to wearing a sensor. They forget they’re wearing a sensor.
ET: Right. And there is cross validation between the 2 measures: the audio recording and the VAL. And if there were some sensitivity, in the audio recording, it probably wouldn’t show up as being as highly correlated.
CV: How did you become interested in studying aphasia therapy?
ET: Well, it occurred to us that language or spoken language was no less of a response than a hand or a key press or a ball press. It has its own characteristics naturally, there’s a difference between manual dexterity and the linguistic content of an utterance. Nevertheless, looking at it, abstractly, there are aspects of spoken language that are similar to a response by hand. And so our hypothesis was that language could be manipulated in the same way as the movements of an extremity could. And this could be used a therapeutic tool for uh improving an impaired function, whether it be the function of a hand or language function. Now, that started out as a hypothesis, we didn’t assert that it was the case, we thought it was possible that it was the case. And so then we took on the CI Therapy I. that I stimulated and carried out in collaboration with Friedemann Pulvermüller in Germany to test that. But I was only there for 2 weeks, twice a year, for a period of years. So I wasn’t able to oversee what was happening. So what we wound up with was a single exercise based on Pulvermuller’s earlier language games which were based on X’s original language games. Lichtenstein was the leader of the Vienna circle and he was a distinguished logical positivist and logical positivists were interested in language. Pulvermuller took Lichtenstein’s language games and published two papers in 1990, and it had a modest effect. When we applied CI therapy principles to it, it had a much much larger effect. But the treatment effect was much more. Then we were getting removed, and it was only a single exercise. With CI therapy, we used a variety of different exercises. And with CI therapy we used movement therapy. We used what we call “transfer package,” to facilitate transfer of what a person did in the treatment setting into the life setting. And with the recognition that what happened in the life setting was all important. What was happening in the treatment setting was of interest, and that was what almost all therapeutic intervention is focused on. But with respect to the person’s quality of life, what is important is not what they are doing in the treatment setting, but what they are doing in the life situation. And if what they were doing in the treatment setting didn’t transfer, then well you’re not really in the rehab business. I mean, one might say, “So what?” You’ve got an improved response or linguistic formulation in the lab. If they can’t formulate language in their life situations, one might ask “So what?” So to speak. We recognize that that is not a traditional point of view, but that is the point of view that we came into the S/L field with. When I got back to UAB I met w/an investigator named Margaret Johnson and Leslie Parker, and others (Michelle Haddad in particular), and we fully translated (or attempted to lawfully translate) the CI movement therapy protocol to a language setting. And we did a variety of things which was described in the paper that we published. The pilot study that we published was in the area of exercises, but we used a transfer package. So that we trained the caregiver to remove language on the part of the caregiver – in particular, to not speak for the patient. That is, in Rickenbauten, two papers by Crotteau, and it is much more common than is taken X therapy unto consideration in the uh SLP literature. Because the caregiver, either because they are very sympathetic to a struggling pt, or they get very patient with the halting “uhhh” expression of the patient, they take over the conversation. And the patient comes to depend on that. As a result, the caregiver frequently, for the best of reasons, winds up suppressing the spontaneous speech of the patient. So we train the caregiver - It’s a very hard habit to break – to not speak for the patient and to carry out a number of mechanisms for promoting spontaneous speech in the home situation. And we do a variety of things to promote that transfer. And when you do that, what you get is a treatment effect that is, after 3 weeks, a 300% improvement in the amount of uh spoken language. And we haven’t published this yet, but we started out with two patients who had very impaired language. At the end of 3 weeks of therapy, they had a standard 300% improvement, which left them about 50-55% amount of speech compared to before stroke. But then, we had the caregiver working with them over the next 3 years which followed the pts. At the end of 2 years, those patients had got very close to the normal speech. 4.8 and 4.9 out of the 5-point scale of the VAL.
GU: One thing that you can’t overemphasize enough is the transfer package that Ed was mentioning. Coming from a psychology background, they are very, so to speak, natural for us. But for scientists and therapists of other disciplines, I think they’re a little unfamiliar. In motor therapy, we found that if you give CI therapy without the transfer package elements, you get about half of the impact on real-world use of the more affected arm. And we’ve also found, in that same study, that it is those elements, the transfer package elements, that are responsible for producing the large widespread structural changes that we have observed in the brain after CI motor therapy.
CV: What advice would you give to clinicians and therapists, especially if they work with patients with aphasia?
GU: I think we would again emphasize the value of these behavioral components that help to transfer gains from the treatment setting to the real world. That’s with respect to therapy. With respect to assessment, again emphasize: Look at what’s going on outside of the treatment setting. And the other thing which we’ve encountered which has been an issue for us with respect to CI movement therapy is testing and doing the therapy completely as it’s described. Because what we’ve experienced with the dissemination of CI movement therapy is: folks have been eager to tinker with it and add on parts or take away parts, and haven’t really followed the published treatment protocol with complete fidelity. And as a result, in the literature, you see a lot of papers that are titled and described as doing CI movement therapy, but they get half or less of the results than we do. But they are treated as CI therapy papers because that is what they’re titled, but the protocol is not faithful to CI therapy.
ET: Difference is they do not use the elements of the transfer package. We describe them, but they’re transparent to PTs and OTs. And I suspect that they’ll also be transparent to SLPs. Because it’s not in their training. And so we describe them, but then people don’t employ them, because they don’t view them as terribly important. They view other aspects of our protocol as central, and it’s difficult to overemphasize the effects of the transfer package for producing effects in the real world.