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NIHR Signal Computerised speech and language therapy can help people with aphasia find words following a stroke

Published on 22 January 2020

doi: 10.3310/signal-000864

People with aphasia caused by a stroke show improvements in retrieving words when they use self-managed computerised speech and language therapy in addition to usual care from a speech and language therapist. No improvements are seen in patients’ conversational abilities or their quality of life.

Aphasia is a complex language and communication disorder. It can affect people’s abilities to read, listen, speak, and write or type. Symptoms vary: some people may mix up a few words, while others have problems with all communication. Speech and language therapists work with patients and their carers to help them improve their speech and use alternative ways of communicating, but there is a shortage of therapists.

This well-conducted NIHR-funded trial shows that adding computerised speech and language therapy to usual care can have some benefits, and is a relatively low-cost intervention. It also highlights areas for further research.

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Why was this study needed?

Aphasia is usually caused by damage to the left side of the brain, most commonly after a stroke. Around 110,000 people in England have a stroke each year. About a third of survivors will have aphasia. Between 30% and 43% of those affected have symptoms in the long term.

Most people make some improvement with speech and language therapy, and some people recover fully. However, speech and language therapy is resource-intensive and difficult to obtain in the NHS. Some small studies have suggested that computerised therapy might be an effective way to provide additional therapy for those who need it. Computer programmes allow patients to complete exercises to help with word-retrieval and other language problems. They can be tailored for individuals and are readily available.

This study aimed to assess the clinical and cost-effectiveness of self-managed computer speech and language therapy used in addition to usual care.

What did this study do?

Big CACTUS was a randomised controlled trial that recruited 278 adults with aphasia from 20 NHS trusts in the UK.

Participants were randomly assigned to one of three groups. The ‘usual care’ group received support from a speech and language therapist. The ‘computerised speech and language therapy’ group had usual care plus six months of using a computer programme daily at home. This was a self-managed set of word-finding exercises, tailored for each individual. There was also an ‘attention control’ group, who received usual care in addition to completing paper-based puzzle book activities (such as Sudoku, or word searches) daily for six months. This last group helped to ensure that any effect could be attributed to the computer intervention rather than just increased attention from a therapist.

This was a robust, albeit relatively small trial, but it was limited to English speakers, as the computer programme was only available in English.

What did it find?

  • On average, participants in the group using a computer had improved word finding of 16.2% more than those in the usual care group (95% confidence interval [CI] 12.7 to 19.6), and 14.4% more than those in the attention control group (95% CI 10.8 to 18.1). This was greater than the pre-specified clinically important difference of 10%. This improvement was maintained at 9 and 12 months.
  • The computer therapy did not improve functional communication. Nor did it have an impact on participants’ own perceptions of their communication, social participation or quality of life.
  • The mean cost per person for the computer therapy was £733. The cost for the equivalent amount of face-to-face time with a speech and language therapist would be approximately £1,400.

What does current guidance say on this issue?

NICE published guidance on stroke rehabilitation in adults in 2013. Its section on communication states that speech and language therapists should provide direct impairment-based therapy for communication impairments such as aphasia. It doesn’t specify what that therapy should be, or how it should be delivered.

The Royal College of Speech and Language Therapists resource manual for commissioning and planning services for aphasia states that computer-based therapy directed by a speech and language therapist is beneficial, cost-effective and acceptable.

What are the implications?

This study shows that self-managed computerised speech and language therapy can be used alongside usual care to improve patients’ ability to retrieve words. Costs come mainly from the time spent by speech and language therapists setting up the software and providing technical support. This could be done by therapy assistants, which would reduce costs.

However, the benefit was limited to word-finding. It did not improve conversation or quality of life. More research is needed to identify ways of helping patients in these areas. In addition, researchers could evaluate other computer programmes. Programmes in languages other than English might also be worth researching further.

Citation and Funding

Palmer R, Dimairo M, Cooper C et al. Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial. Lancet Neurol. 2019;18:821-33.

This project was funded by the NIHR Health Technology Assessment Programme (project number 12/21/01) and the Tavistock Trust for Aphasia.

Bibliography

Brady MC, Kelly H, Godwin J et al. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2016;(6):CD000425.

NHS website. Aphasia. London: Department of Health and Social Care; updated 2018.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCSLT. RCSLT resource manual for commissioning and planning services for SLCN: aphasia. London: Royal College of Speech and Language Therapists; 2009 (updated 2014).

Why was this study needed?

Aphasia is usually caused by damage to the left side of the brain, most commonly after a stroke. Around 110,000 people in England have a stroke each year. About a third of survivors will have aphasia. Between 30% and 43% of those affected have symptoms in the long term.

Most people make some improvement with speech and language therapy, and some people recover fully. However, speech and language therapy is resource-intensive and difficult to obtain in the NHS. Some small studies have suggested that computerised therapy might be an effective way to provide additional therapy for those who need it. Computer programmes allow patients to complete exercises to help with word-retrieval and other language problems. They can be tailored for individuals and are readily available.

This study aimed to assess the clinical and cost-effectiveness of self-managed computer speech and language therapy used in addition to usual care.

What did this study do?

Big CACTUS was a randomised controlled trial that recruited 278 adults with aphasia from 20 NHS trusts in the UK.

Participants were randomly assigned to one of three groups. The ‘usual care’ group received support from a speech and language therapist. The ‘computerised speech and language therapy’ group had usual care plus six months of using a computer programme daily at home. This was a self-managed set of word-finding exercises, tailored for each individual. There was also an ‘attention control’ group, who received usual care in addition to completing paper-based puzzle book activities (such as Sudoku, or word searches) daily for six months. This last group helped to ensure that any effect could be attributed to the computer intervention rather than just increased attention from a therapist.

This was a robust, albeit relatively small trial, but it was limited to English speakers, as the computer programme was only available in English.

What did it find?

  • On average, participants in the group using a computer had improved word finding of 16.2% more than those in the usual care group (95% confidence interval [CI] 12.7 to 19.6), and 14.4% more than those in the attention control group (95% CI 10.8 to 18.1). This was greater than the pre-specified clinically important difference of 10%. This improvement was maintained at 9 and 12 months.
  • The computer therapy did not improve functional communication. Nor did it have an impact on participants’ own perceptions of their communication, social participation or quality of life.
  • The mean cost per person for the computer therapy was £733. The cost for the equivalent amount of face-to-face time with a speech and language therapist would be approximately £1,400.

What does current guidance say on this issue?

NICE published guidance on stroke rehabilitation in adults in 2013. Its section on communication states that speech and language therapists should provide direct impairment-based therapy for communication impairments such as aphasia. It doesn’t specify what that therapy should be, or how it should be delivered.

The Royal College of Speech and Language Therapists resource manual for commissioning and planning services for aphasia states that computer-based therapy directed by a speech and language therapist is beneficial, cost-effective and acceptable.

What are the implications?

This study shows that self-managed computerised speech and language therapy can be used alongside usual care to improve patients’ ability to retrieve words. Costs come mainly from the time spent by speech and language therapists setting up the software and providing technical support. This could be done by therapy assistants, which would reduce costs.

However, the benefit was limited to word-finding. It did not improve conversation or quality of life. More research is needed to identify ways of helping patients in these areas. In addition, researchers could evaluate other computer programmes. Programmes in languages other than English might also be worth researching further.

Citation and Funding

Palmer R, Dimairo M, Cooper C et al. Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial. Lancet Neurol. 2019;18:821-33.

This project was funded by the NIHR Health Technology Assessment Programme (project number 12/21/01) and the Tavistock Trust for Aphasia.

Bibliography

Brady MC, Kelly H, Godwin J et al. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2016;(6):CD000425.

NHS website. Aphasia. London: Department of Health and Social Care; updated 2018.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCSLT. RCSLT resource manual for commissioning and planning services for SLCN: aphasia. London: Royal College of Speech and Language Therapists; 2009 (updated 2014).

Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS) : a multicentre, single-blinded, randomised controlled trial.

Published on 1 September 2019

Palmer R, Dimairo M, Cooper C, Enderby P, Brady M, Bowen A, Latimer N, Julious S, Cross E, Alshreef A , Harrison M, Bradley E, Witts H, Chater T.

Lancet Neurology , 2019

Background Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone. Methods In this pragmatic, superiority, three-arm, individually randomised, single-blind, parallel group trial, patients were recruited from 21 speech and language therapy departments in the UK. Participants were aged 18 years or older and had been diagnosed with aphasia post-stroke at least 4 months before randomisation; they were excluded if they had another premorbid speech and language disorder caused by a neurological deficit other than stroke, required treatment in a language other than English, or if they were currently using computer-based word-finding speech therapy. Participants were randomly assigned (1:1:1) to either 6 months of usual care (usual care group), daily self-managed CSLT plus usual care (CSLT group), or attention control plus usual care (attention control group) with the use of computer-generated stratified blocked randomisation (randomly ordered blocks of sizes three and six, stratified by site and severity of word finding at baseline based on CAT Naming Objects test scores). Only the outcome assessors and trial statistician were masked to the treatment allocation. The speech and language therapists who were doing the outcome assessments were different from those informing participants about which group they were assigned to and from those delivering all interventions. The statistician responsible for generating the randomisation schedule was separate from those doing the analysis. Co-primary outcomes were the change in ability to retrieve personally relevant words in a picture naming test (with 10% mean difference in change considered a priori as clinically meaningful) and the change in functional communication ability measured by masked ratings of video-recorded conversations, with the use of Therapy Outcome Measures (TOMs), between baseline and 6 months after randomisation (with a standardised mean difference in change of 0·45 considered a priori as clinically meaningful). Primary analysis was based on the modified intention-to-treat (mITT) population, which included randomly assigned patients who gave informed consent and excluded those without 6-month outcome measures. Safety analysis included all participants. This trial has been completed and was registered with the ISRCTN, number ISRCTN68798818. Findings From Oct 20, 2014, to Aug 18, 2016, 818 patients were assessed for eligibility, of which 278 (34%) participants were randomly assigned (101 [36%] to the usual care group; 97 [35%] to the CSLT group; 80 [29%] to the attention control group). 86 patients in the usual care group, 83 in the CSLT group, and 71 in the attention control group contributed to the mITT. Mean word finding improvements were 1·1% (SD 11·2) in the usual care group, 16·4% (15·3) in the CSLT group, and 2·4% (8·8) in the attention control group. Word finding improvement was 16·2% (95% CI 12·7 to 19·6; p<0·0001) higher in the CSLT group than in the usual care group and was 14·4% (10·8 to 18·1) higher than in the attention control group. Mean changes in TOMs were 0·05 (SD 0·59) in the usual care group (n=84), 0·04 (0·58) in the CSLT group (n=81), and 0·10 (0·61) in the attention control group (n=68); the mean difference in change between the CSLT and usual care groups was –0·03 (–0·21 to 0·14; p=0·709) and between the CSLT and attention control groups was –0·01 (–0·20 to 0·18). The incidence of serious adverse events per year were rare with 0·23 events in the usual care group, 0·11 in the CSLT group, and 0·16 in the attention control group. 40 (89%) of 45 serious adverse events were unrelated to trial activity and the remaining five (11%) of 45 serious adverse events were classified as unlikely to be related to trial activity. Interpretation CSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. Funding National Institute for Health Research, Tavistock Trust for Aphasia.

Expert commentary

People with aphasia need long-lasting intensive practice to improve their language skills and participate in everyday communication again. Computer-based speech and language therapy allows such drill, both self-administered to enhance frequency and supervised to direct choice of methods, potentially leading to optimal therapy outcome.

This important study shows that such independent but supervised treatment improves language skills, and therefore speech and language therapists may increasingly choose this treatment opportunity for their clients, besides usual care.

To further change clinical practice, ways to motivate clients to regularly use such treatment at high frequency and integrate it into their daily routine need to be explored.

Dr Stefanie Bruehl, Director of SLT and Music Therapy, St Mauritius Rehabilitation Centre, Meerbusch, Germany; Adjunct Professor at RWTH Aachen University, Germany; Honorary Clinical Senior Lecturer, University of Manchester

The commentator declares no conflicting interests