For the second time this year, Team ReSNetSLT are delighted that we can introduce you to another clinical SLT to lead our tweetchat discussions.
Welcome to Charlotte Howland, known to her friends as Charlie.
Charlie is a Speech and Language Therapist at Barts Trust NHS.
She currently works as a Highly Specialist Speech and Language Therapist at The Royal London Hospital and has recently completed her Stroke Medicine MSc from UCL earlier this year.
For her outstanding achievement and scoring the highest overall mark on the programme, Charlie was awarded the Lindsay Symon prize.
Following on from Stroke awareness month in May 2021, this month’s Tweetchat is focusing on the theme of aphasia.
This chat will be hosted by Charlie @churrrlie and as usual, other members of our usual team will be supporting the chat, with special thanks to Ellie.
Here’s the link to the open-access paper Charlie has chosen:
Please read on for Charlie’s introduction to this paper, including the research design and patient interventions.
At the end of the post you will see the questions that we will use to structure our tweetchat and invite everyone to share your own insights on:
– the implications of these findings for your local services
– comments about feasibility of application into your practice (especially re-intervention intensity).
Introduction to the paper:
This paper aimed to determine whether intensive, early aphasia therapy (within 14 days post-stroke) improved communication recovery compared to usual care.
A total of 245 patients were included in this study from Australia and New Zealand, and followed up from point of admission to hospital, to 26 weeks post-stroke.
Patient characteristics:
- Inclusion: Adults aged over 18 admitted with acute stroke and mild to severe aphasia of any type as judged by performance of composite score of <93.7 on the WAB-R. Patients needed to be medically stable, maintain alertness for >30 minutes, and had normal or corrected hearing and vision.
- Exclusion: Pre-existing aphasia or dementia, progressive neurological condition, history of head injury, neurosurgery, clinical depression on admission, inability to participate in English based therapy, or participation in other intervention trials.
- Patient characteristics: This study also describes various patient characteristics such as demographics (age, sex, social history, stroke risk factors), baseline NIHSS on admission, Oxford stroke classification, whether patients received rTPA, presence of apraxia/dysarthria, and whether a cognitive assessment was completed). Of note, a high proportion of patients were described to have apraxia in this study (47% in the usual care group and 48% in the intensive treatment group).
Patient groups and intervention received:
- Randomisation: A block randomised sequence was used to randomise patients to one of three groups, stratified by aphasia severity determined by the WAB-R:
- 81 patients in the ‘Usual Care’ group. These patients received treatment as per standard care of the treating site. Some patients (n=4) did not receive any intervention at all.
- 82 patients in the ‘Usual Care Plus’ group. These patients received ‘usual care’ plus 20 sessions of aphasia therapy commencing before day 15 and completed within four weeks. Aphasia therapy could be individual, group, impairment-based or social/communication device training at the discretion of the treating clinician.
- 84 patients in the ‘VERSE’ group. These patients received 20 sessions of aphasia therapy commencing before day 15 and completed within four weeks. VERSE therapy was an impairment-based therapy program prioritising error-free, verbal communication while working between 50-80% accuracy at each goal level.
- Blinding: participants, family members, ward staff and outcome assessors were blinded to group allocation. Only treating therapists (acute and subacute) were unblinded to treatment allocation.
Outcome measures:
- Primary outcome measure: WAB-R composite score at 12 weeks. A 5 point change on the WAB-R represented a clinically meaningful effect in this study.
- Secondary outcome measures: WAB-R score and discourse measure at 26 weeks. The discourse measure was ‘number of words’, ‘number of correct information units’ and ‘% correct information units’. Other secondary outcome measures were the Boston Naming Test, Stroke and Aphasia Quality of Life Scale-39, Aphasia Depression Rating Scale, all at 12 and 26 weeks.
Results:
- All patients achieved significant, clinically meaningful gains in language recovery, regardless of group allocation. Authors feel that this recovery was likely due to a combination of spontaneous recovery, plus treatment effect.
- There was no statistically significant difference between any of the groups at either 12 or 26 weeks on either the primary or secondary outcome measures (language impairment, discourse/connected speech, quality of life, or depression).
Discussion:
- Authors were surprised at the results because they felt that patients receiving higher intervention would show greater gains than ‘usual care’. They hypothesise there are “diminishing marginal returns” from the addition of increasing amounts of aphasia therapy sessions provided, thus challenging the belief that ‘more intensive therapy is better’. Finally, they state that their results do not support increasing aphasia therapy intensity in the first 38 days post-stroke above what is reported as ‘usual care’ in this trial, nor support the modification of existing services.
- Authors do identify the need for future research, specifically regarding: (i) the dose-response in early and chronic aphasia recovery; (ii) the optimal type of therapy to provide to whom and at what time post-stroke; (iii) what other factors contribute to early aphasia recovery.
Summary:
- Although this study demonstrates there was no difference in language outcomes for patients receiving usual care vs. intensive aphasia therapy, further thought and follow up studies could consider how patient factors, selection of outcome measures, and choice of intervention approach may have contributed to the null result.
- With respect to patient factors: Further investigation of ‘brain’ and ‘behaviour’ factors may be helpful to understand response to treatment, as these are known to influence recovery from aphasia. With respect to ‘brain’, consideration of the influence of lesion size (volume) and/or location of stroke (i.e. direct damage to critical speech and language areas, or ‘disconnection’ of these areas due to loss of white matter tracts). With respect to ‘behaviour’, considering the influence of non-language cognitive abilities (e.g. executive function, reasoning, attention, problem-solving, verbal and visuospatial working memory) which are necessary to successfully participate and make meaningful gains in rehabilitation i.e. patients’ ‘capacity to learn’.
- With respect to outcome measures: Whilst this study included a variety of qualitative and quantitative outcome measures, these may not have been sensitive or specific enough to detect change. The primary outcome measure of this study was a composite score (WAB-R Aphasia Quotient) which captures performance across eight subscales across domains of verbal output, auditory comprehension, reading and writing. The VERSE group of the study were provided with intervention that focused on improving verbal output only, specifically, error-free production of verbal communication using a strict cueing hierarchy. Finally, consideration of the implications of frequently testing patients with the same standardised assessment battery at three time points in this study.
- With respect to treatment approach: As stated above, the VERSE arm of the study had a focus on addressing impairment-based goals; specifically, error-free speech. A similar treatment approach was employed for all patients with aphasia, regardless of aphasia severity or the nature of their difficulties. This may have influenced results, particularly if this approach was not appropriate for all patients.
Questions for the chat:
- What kind of non-language factors do you consider that may contribute to recovery from aphasia?
- What kind of outcome measures do you use for patients with aphasia?
- What other research are you aware of regarding intensity and frequency of aphasia therapy? How does this compare to your own service delivery?
- What do you think are the key implications of this research article for our profession and service delivery?