Disclaimer: this resource is intended for speech and language therapists and students of this profession. If you require therapy for aphasia please contact a speech and language therapist.
Constraint Induced Language Therapy (CILT)
Summary: Constraint Induced Language Therapy (CILT) is based on an earlier physical therapy treatment known as Constraint Induced Movement Therapy (CIMT). CIMT holds that, following a stroke, people tend to avoid the use of impaired limbs and that their potential for rehabilitation is limited as a result (Taub et al., 1999). Applying this to aphasia therapy, Pulvermüller et al. (2001) developed CILT, a therapy that prompts the person with aphasia to use verbal output by constraining their use of alternative means of communication, i.e. the client is not permitted to use strategies such as drawing, writing or gesturing to communicate.
Example: CILT is conducted as a therapeutic game activity in small groups (2-3 clients and a therapist per group). It can be helpful to have a second therapist present to facilitate and provide reinforcement. 32 picture cards are used, made up of 16 pictures with 2 copies of each picture card. The cards depict objects that are either high-frequency, low-frequency or which have a phonological similarity with one of the other picture cards in the deck (e.g. "man" & "mat"). The complexity of language required to complete the game can be increased by including, for example, similar pairs that differ only in colour. Barriers are placed around each client’s cards to prevent their cards being seen by other clients.
The game is played as follows:
1) Each client is dealt a set of cards (e.g. 4 cards). These are seen only by the client they are dealt to.
2) The client then turns to one of the other players and verbally requests a the picture card that matches one of the cards they were dealt, e.g. “James, do you have the tree?”.
3) If the other player has this card, they acknowledge this verbally (e.g. “Yes, I have the tree”) and give it to the client. If the player does not have the picture card that was requested, they state this verbally (e.g. “No, I don’t have the tree”). Use of gestures, pointing or any other means of communication is not allowed.
4) The therapist facilitates by providing phonological or semantic cues and, where necessary, reminding clients to use only verbal communication.
5) The round ends when a client has matched all of their cards.
Adapted from Pulvermüller et al. (2001) & Meinzer et al. (2012).
The game is played as follows:
1) Each client is dealt a set of cards (e.g. 4 cards). These are seen only by the client they are dealt to.
2) The client then turns to one of the other players and verbally requests a the picture card that matches one of the cards they were dealt, e.g. “James, do you have the tree?”.
3) If the other player has this card, they acknowledge this verbally (e.g. “Yes, I have the tree”) and give it to the client. If the player does not have the picture card that was requested, they state this verbally (e.g. “No, I don’t have the tree”). Use of gestures, pointing or any other means of communication is not allowed.
4) The therapist facilitates by providing phonological or semantic cues and, where necessary, reminding clients to use only verbal communication.
5) The round ends when a client has matched all of their cards.
Adapted from Pulvermüller et al. (2001) & Meinzer et al. (2012).
Evidence Base: Numerous studies indicate that CILT significantly improves both the quantity and quality of expressive language for participants with aphasia. For example, Pulvermüller et al. (2001) compared the effects of conventional aphasia therapy with CILT for participants with chronic aphasia (17 participants total, 10 participants received CILT). Conventional aphasia therapy here involved ‘naming, repetition, sentence completion, following instructions, and conversations on topics of the patients’ own choice’. Participants in both groups received the same amount of therapy time (23-33 hours). Both therapies resulted in significant improvements, however this was more marked for those who received CILT. Furthermore, participants who received CILT appeared to use more language outside of therapy. This was not the case for the conventional aphasia therapy group.
It is not clear which feature of CILT leads to these changes. It may be the intensity with which the therapy is delivered (3-4 hours for 10 days in the Pulvermüller study, above) that leads to the gains outlined above. Studies that compare CILT with other aphasia therapies whilst controlling for intensity of therapy indicate no significant difference on language measures between treatments (Maher et al., 2006; Barthel et al., 2008). However, Maher et al., who compared CILT with Promoting Aphasics’ Communicative Effectiveness treatment, did report that participants who received CILT showed better ability to convey narratives and maintenance of gains at 1 month follow-up relative to the Promoting Aphasics’ Communicative Effectiveness treatment group.
It is not clear which feature of CILT leads to these changes. It may be the intensity with which the therapy is delivered (3-4 hours for 10 days in the Pulvermüller study, above) that leads to the gains outlined above. Studies that compare CILT with other aphasia therapies whilst controlling for intensity of therapy indicate no significant difference on language measures between treatments (Maher et al., 2006; Barthel et al., 2008). However, Maher et al., who compared CILT with Promoting Aphasics’ Communicative Effectiveness treatment, did report that participants who received CILT showed better ability to convey narratives and maintenance of gains at 1 month follow-up relative to the Promoting Aphasics’ Communicative Effectiveness treatment group.
References
Barthel, G., Meinzer, M., Djundja, D., & Rockstroh, B., 2008. Intensive language therapy in chronic aphasia: Which aspects contribute most? Aphasiology. 22,408–421
Maher, L., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S., Pingel, K., Holland, A., & Gonzalez-Rothi, L., 2006. A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12(6), 843-852
Meinzer, M., Rodriguez, A.D., & Gonzalez Rothi, L.J., 2012. The first decade of research on constrained-induced treatment approaches for aphasia rehabilitation. Archives of Physical Medicine and Rehabilitation. 93(1 Suppl.), S35-S45
Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E., 2001. Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621- 1626
Taub, E., Uswatte, G., & Pidikiti, R., 1999. Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation- a clinical review. Journal of Rehabilitation Research and Development, 36, 237-251
Barthel, G., Meinzer, M., Djundja, D., & Rockstroh, B., 2008. Intensive language therapy in chronic aphasia: Which aspects contribute most? Aphasiology. 22,408–421
Maher, L., Kendall, D., Swearengin, J., Rodriguez, A., Leon, S., Pingel, K., Holland, A., & Gonzalez-Rothi, L., 2006. A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy. Journal of the International Neuropsychological Society, 12(6), 843-852
Meinzer, M., Rodriguez, A.D., & Gonzalez Rothi, L.J., 2012. The first decade of research on constrained-induced treatment approaches for aphasia rehabilitation. Archives of Physical Medicine and Rehabilitation. 93(1 Suppl.), S35-S45
Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E., 2001. Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621- 1626
Taub, E., Uswatte, G., & Pidikiti, R., 1999. Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation- a clinical review. Journal of Rehabilitation Research and Development, 36, 237-251
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