NIHR Signal Intensive speech therapy helps stroke survivors with persistent communication difficulties

Published on 18 July 2017

Intensive speech and language therapy begun six months or more after a stroke improved verbal communication, language comprehension and self-reported quality of life for those with persistent communication difficulties (chronic aphasia).

The therapy in this trial consisted of around 30 hours over three weeks. Participants who received low-intensity therapy (around one hour per week) whilst on a waiting list did not improve during that time. NICE guidelines recommend speech and language therapy immediately after a stroke and if the person still experiences communication difficulties six months after their stroke, but do not specify the intensity of the therapy.

This trial highlights the modest benefits of providing further intensive speech and language therapy for stroke survivors who continue to have aphasia after six months. The Royal College of Speech and Language Therapists previously raised concerns about lack of access to this type of therapy. However before implementation it will be important to know which component of therapy is providing the benefits and how much it costs compared to alternatives.

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Why was this study needed?

As treatment of strokes improves there are increasing numbers of stroke survivors requiring help and support to enable them to live their life to the fullest. A third of the UK’s 1.1 million stroke survivors experience communication difficulties.

Aphasia affects how people choose which words to use and combine them into sentences, affecting both speech and writing. People with aphasia can also experience difficulties in understanding words and sentences. Depression is common after stroke and could be worsened by an inability to communicate.

Speech and language therapy can help people with aphasia to communicate more effectively. There have been randomised controlled trials investigating its effectiveness, but these have generally been small, short and of low methodological quality. This limits our confidence in their findings.

This randomised controlled trial investigated the effectiveness of intensive speech and language therapy in people who still had aphasia six months or more after a stroke.

What did this study do?

The FCET2EC (From Controlled Experimental Trial 2 Everyday Communication) trial randomly allocated 156 German people with chronic aphasia to immediately receive intensive speech and language therapy, or stay on a waiting list for three weeks before receiving therapy. Participants had an average age of 53 and the stroke had occurred between one and six years previously.

The intensive therapy intervention took place over three weeks. Each group had one-to-one sessions (22 hours), group therapy (nine hours) and self-led exercises (15 hours). Over 90% of participants continued with one hour of therapy per week in the six month follow-up.

This was a well-designed trial with reliable results. However, it did not consider cost effectiveness and the therapy is more intensive than current NHS speech and language therapy.

What did it find?

  • Average scores for the effectiveness of verbal communication were higher after three weeks of intensive therapy. Using the ANELT A-scale, a 50 point scoring system where higher scores are better, intensive therapy increased the score by 2.61 points to 31.39 compared to no change for people on the waiting list. A one point improvement could mean going from not being able to communicate at all to having basic communication capabilities.
  • Compared to people on the waiting list, people who received therapy had moderately higher scores in linguistic tests – including language comprehension and production (effect size 0.73). People who received therapy also better self-reported quality of life (effect size 0.27).
  • Three weeks after each group had received intensive therapy, 44% of people had an improvement of at least three points in verbal communication.

What does current guidance say on this issue?

Following a stroke, NICE recommends that people are screened for communication difficulties within 72 hours and referred for speech and language therapy if needed. Individuals can be re-referred if communication difficulties persist six months after their stroke.

Speech and language therapy aims to enable the person to make the most of their communication abilities, teaching other communication methods (gestures, writing, using props) and coaching people around them (such as family members) to help maximise their communication potential. This helps the individual to adjust to their communication impairment, build their confidence and rebuild their identity to participate in everyday life.

What are the implications?

Speech and language therapy has generally been considered most effective in the six months following a stroke. However, this trial suggests that intensive therapy can modestly improve the communication capabilities and quality of life of people with chronic aphasia if begun six months or more after their stroke.

The control participants who received low-intensity therapy whilst on a waiting list did not improve, suggesting that the intensity or time spent in therapy impacts on its effectiveness.

The resource availability and its cost may limit the ability of the NHS to offer high intensity therapy, but this new evidence alongside further evaluation of the costs and intensity required could contribute to the case for making this sort of therapy more widely available.

Citation and Funding

Breitenstein C, Grewe T, Flöel A, et al; FCET2EC study group. Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. Lancet. 2017;389(10078):1528-38.

This trial was funded by the German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Bibliography

NHS Choices. Aphasia. London: Department of Health; 2015.

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

RCSLT. Supporting stroke survivors. London: Royal College of Speech and Language Therapists.

Why was this study needed?

As treatment of strokes improves there are increasing numbers of stroke survivors requiring help and support to enable them to live their life to the fullest. A third of the UK’s 1.1 million stroke survivors experience communication difficulties.

Aphasia affects how people choose which words to use and combine them into sentences, affecting both speech and writing. People with aphasia can also experience difficulties in understanding words and sentences. Depression is common after stroke and could be worsened by an inability to communicate.

Speech and language therapy can help people with aphasia to communicate more effectively. There have been randomised controlled trials investigating its effectiveness, but these have generally been small, short and of low methodological quality. This limits our confidence in their findings.

This randomised controlled trial investigated the effectiveness of intensive speech and language therapy in people who still had aphasia six months or more after a stroke.

What did this study do?

The FCET2EC (From Controlled Experimental Trial 2 Everyday Communication) trial randomly allocated 156 German people with chronic aphasia to immediately receive intensive speech and language therapy, or stay on a waiting list for three weeks before receiving therapy. Participants had an average age of 53 and the stroke had occurred between one and six years previously.

The intensive therapy intervention took place over three weeks. Each group had one-to-one sessions (22 hours), group therapy (nine hours) and self-led exercises (15 hours). Over 90% of participants continued with one hour of therapy per week in the six month follow-up.

This was a well-designed trial with reliable results. However, it did not consider cost effectiveness and the therapy is more intensive than current NHS speech and language therapy.

What did it find?

  • Average scores for the effectiveness of verbal communication were higher after three weeks of intensive therapy. Using the ANELT A-scale, a 50 point scoring system where higher scores are better, intensive therapy increased the score by 2.61 points to 31.39 compared to no change for people on the waiting list. A one point improvement could mean going from not being able to communicate at all to having basic communication capabilities.
  • Compared to people on the waiting list, people who received therapy had moderately higher scores in linguistic tests – including language comprehension and production (effect size 0.73). People who received therapy also better self-reported quality of life (effect size 0.27).
  • Three weeks after each group had received intensive therapy, 44% of people had an improvement of at least three points in verbal communication.

What does current guidance say on this issue?

Following a stroke, NICE recommends that people are screened for communication difficulties within 72 hours and referred for speech and language therapy if needed. Individuals can be re-referred if communication difficulties persist six months after their stroke.

Speech and language therapy aims to enable the person to make the most of their communication abilities, teaching other communication methods (gestures, writing, using props) and coaching people around them (such as family members) to help maximise their communication potential. This helps the individual to adjust to their communication impairment, build their confidence and rebuild their identity to participate in everyday life.

What are the implications?

Speech and language therapy has generally been considered most effective in the six months following a stroke. However, this trial suggests that intensive therapy can modestly improve the communication capabilities and quality of life of people with chronic aphasia if begun six months or more after their stroke.

The control participants who received low-intensity therapy whilst on a waiting list did not improve, suggesting that the intensity or time spent in therapy impacts on its effectiveness.

The resource availability and its cost may limit the ability of the NHS to offer high intensity therapy, but this new evidence alongside further evaluation of the costs and intensity required could contribute to the case for making this sort of therapy more widely available.

Citation and Funding

Breitenstein C, Grewe T, Flöel A, et al; FCET2EC study group. Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. Lancet. 2017;389(10078):1528-38.

This trial was funded by the German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Bibliography

NHS Choices. Aphasia. London: Department of Health; 2015.

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

RCSLT. Supporting stroke survivors. London: Royal College of Speech and Language Therapists.

Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting

Published on 4 March 2017

Breitenstein, C.,Grewe, T.,Floel, A.,Ziegler, W.,Springer, L.,Martus, P.,Huber, W.,Willmes, K.,Ringelstein, E. B.,Haeusler, K. G.,Abel, S.,Glindemann, R.,Domahs, F.,Regenbrecht, F.,Schlenck, K. J.,Thomas, M.,Obrig, H.,de Langen, E.,Rocker, R.,Wigbers, F.,Ruhmkorf, C.,Hempen, I.,List, J.,Baumgaertner, A.

Lancet , 2017

BACKGROUND: Treatment guidelines for aphasia recommend intensive speech and language therapy for chronic (>/=6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke. METHODS: In this multicentre, parallel group, superiority, open-label, blinded-endpoint, randomised controlled trial, patients aged 70 years or younger with aphasia after stroke lasting for 6 months or more were recruited from 19 inpatient or outpatient rehabilitation centres in Germany. An external biostatistician used a computer-generated permuted block randomisation method, stratified by treatment centre, to randomly assign participants to either 3 weeks or more of intensive speech and language therapy (>/=10 h per week) or 3 weeks deferral of intensive speech and language therapy. The primary endpoint was between-group difference in the change in verbal communication effectiveness in everyday life scenarios (Amsterdam-Nijmegen Everyday Language Test A-scale) from baseline to immediately after 3 weeks of treatment or treatment deferral. All analyses were done using the modified intention-to-treat population (those who received 1 day or more of intensive treatment or treatment deferral). This study is registered with ClinicalTrials.gov, number NCT01540383. RESULTS: We randomly assigned 158 patients between April 1, 2012, and May 31, 2014. The modified intention-to-treat population comprised 156 patients (78 per group). Verbal communication was significantly improved from baseline to after intensive speech and language treatment (mean difference 2.61 points [SD 4.94]; 95% CI 1.49 to 3.72), but not from baseline to after treatment deferral (-0.03 points [4.04]; -0.94 to 0.88; between-group difference Cohen's d 0.58; p=0.0004). Eight patients had adverse events during therapy or treatment deferral (one car accident [in the control group], two common cold [one patient per group], three gastrointestinal or cardiac symptoms [all intervention group], two recurrent stroke [one in intervention group before initiation of treatment, and one before group assignment had occurred]); all were unrelated to study participation. INTERPRETATION: 3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke, providing an effective evidence-based treatment approach in this population. Future studies should examine the minimum treatment intensity required for meaningful treatment effects, and determine whether treatment effects cumulate over repeated intervention periods. FUNDING: German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Expert commentary

Imagine suddenly losing the ability to communicate your thoughts and feelings, or to understand what you hear or read. This is aphasia and it happens to many stroke survivors. Now imagine being told your chances of recovery will “plateau” after six months and therapy is pointless. This important study ends that nihilism. People with chronic aphasia can benefit from support and improve their everyday communication.

To change practice we next need to find out whether this benefit is due to general language stimulation or psychological well-being from spending time with a caring professional, or if it requires the specific therapy.

Audrey Bowen, Stroke Association John Marshall Memorial Professor of Neuropsychological Rehabilitation

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