Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial
Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ 2012;345:e4407.
We must congratulate Bowen et al, and not tamely, for undertaking this massive study into the effectiveness of intervention for aphasia and dysarthria. As someone who was part of a competing application for the same funding, I am aware of the amount of work involved in simply designing and planning such a project, never mind the actual implementation of it.
But what do we now know that we didn’t know before? A fair conclusion seems to be that generalized ‘intervention’ that is determined by a trained clinician to be appropriate for a particular client delivered within the first 4 months post stroke is no more effective than contact from an ‘trained’ and closely ‘monitored visitors’.
We can of course raise specific issues with the design and implementation of the study, as with most studies:
The intervention took place in the acute first 4 months post-stroke while spontaneous recovery was taking place and even though the intervention and control groups were well matched on most crucial variables, spontaneous recovery we might assume was responsible for some at least of the observed improvement. Most studies of effectiveness of intervention for aphasia are with chronically aphasic people for this reason.
We might question the choice of some of the assessment materials, even though they were well-established and psychometrically robust measures. Others might have chosen a Health Related QOL measure, a standardized aphasia battery or employed psychometrically controlled tests.
We might question how unskilled the control visitors were. They are described as having ‘excellent social skills and general competency and were trained to deliver social attention’, so not even ‘averagely’ good at social interaction, but ‘excellent’. There is a very significant move in the English-speaking world towards involving conversational partners in the intervention we provide for aphasic people (1) and we might argue that the visitors provided social interaction much like a good aphasia therapist would.
We might wonder at the exclusion of 'apraxia of speech' from intervention, given that a significant proportion of aphasi people have apraxia of speech as part of their aphasic profile.
What the study does not demonstrate is that aphasia intervention is ineffective. Many aphasia clinicians utilize more specific approaches to treatment for impairments, and future well-designed studies of the effectiveness of theoretically based approaches that have shown promise or specific variables that research suggests are particularly important, such as Constraint Induced Aphasia Treatment (2,3) or repetitive Transcranial Magnetic Stimulation (4) and the variables of intensity, which research suggests is particularly important (5).
The complexity of aphasia is one reason why designing and delivering such interventions within large group designs is fraught with difficulties. But it is a concept in constant motion as we learn more about just how complex aphasia is. Any individual aphasic person will have a pattern of separate symptoms at different severities which can emerge at different times post-onset (e.g., anomia, apraxia of speech, comprehension impairments, sentence processing impairments, repetition impairments, perseveration, speech automatisms, etc.), but they can also have significant associated cognitive difficulties with working memory, attention, apraxias, fatigue, which may all underlie different ‘aphasic’ symptoms. Having a theoretical understanding of the causes of specific symptoms would appear essential to designing interventions. So the design of studies to examine the effectiveness of interventions becomes even harder.
There is no magical component to aphasia therapy, even to the very best therapy, and aphasia therapists are simply well trained to provide the best treatment they can for aphasic people. That their efforts appear not to produce much more improvement than trained and skilled social interactors may not therefore be such a surprise. Many have suggested that, for the reasons sketched above, not to mention the costs of staging such large projects, single case designs are far more valid and the outcomes more reliable, especially when a series of similar single cases can be evaluated together (6).
1. Kagan, A (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners. Aphasiology, 12, 816-830
2. Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia following stroke. Stroke, 32, 1621-1626.
3. Meinzer, M., Djundja, D., Barthel, G., Elbert, T., & Rockstroh, B. (2005). Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36(7), 1462-1466.
4. Holland, R. & Crinion, J. (2012) Can tDCS enhance treatment of aphasia after stroke? Aphasilogy, Online version: DOI:10.1080/02687038.2011.616925
5. Bhogal, S. K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34, 987–993.
6. Robey, R. R., Schultz, M. C., Crawford, A. B., & Sinner, C. A. (1999). Single-subject clinical-outcome research: Designs, data, effect sizes, and analyses. Aphasiology, 13, 445–473.
Competing interests:
I was involved in a competing bid for the same funding to undertake a large multi-centre study of the effectiveness of treatment for aphasia.
11 August 2012
Chris Code
Honorary Professor
University of Exeter
Psychology, College of Life & Environmental Studies, Washington Singer Labs, University of Exeter, EX4 4QG
Rapid Response:
Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial
Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ 2012;345:e4407.
We must congratulate Bowen et al, and not tamely, for undertaking this massive study into the effectiveness of intervention for aphasia and dysarthria. As someone who was part of a competing application for the same funding, I am aware of the amount of work involved in simply designing and planning such a project, never mind the actual implementation of it.
But what do we now know that we didn’t know before? A fair conclusion seems to be that generalized ‘intervention’ that is determined by a trained clinician to be appropriate for a particular client delivered within the first 4 months post stroke is no more effective than contact from an ‘trained’ and closely ‘monitored visitors’.
We can of course raise specific issues with the design and implementation of the study, as with most studies:
The intervention took place in the acute first 4 months post-stroke while spontaneous recovery was taking place and even though the intervention and control groups were well matched on most crucial variables, spontaneous recovery we might assume was responsible for some at least of the observed improvement. Most studies of effectiveness of intervention for aphasia are with chronically aphasic people for this reason.
We might question the choice of some of the assessment materials, even though they were well-established and psychometrically robust measures. Others might have chosen a Health Related QOL measure, a standardized aphasia battery or employed psychometrically controlled tests.
We might question how unskilled the control visitors were. They are described as having ‘excellent social skills and general competency and were trained to deliver social attention’, so not even ‘averagely’ good at social interaction, but ‘excellent’. There is a very significant move in the English-speaking world towards involving conversational partners in the intervention we provide for aphasic people (1) and we might argue that the visitors provided social interaction much like a good aphasia therapist would.
We might wonder at the exclusion of 'apraxia of speech' from intervention, given that a significant proportion of aphasi people have apraxia of speech as part of their aphasic profile.
What the study does not demonstrate is that aphasia intervention is ineffective. Many aphasia clinicians utilize more specific approaches to treatment for impairments, and future well-designed studies of the effectiveness of theoretically based approaches that have shown promise or specific variables that research suggests are particularly important, such as Constraint Induced Aphasia Treatment (2,3) or repetitive Transcranial Magnetic Stimulation (4) and the variables of intensity, which research suggests is particularly important (5).
The complexity of aphasia is one reason why designing and delivering such interventions within large group designs is fraught with difficulties. But it is a concept in constant motion as we learn more about just how complex aphasia is. Any individual aphasic person will have a pattern of separate symptoms at different severities which can emerge at different times post-onset (e.g., anomia, apraxia of speech, comprehension impairments, sentence processing impairments, repetition impairments, perseveration, speech automatisms, etc.), but they can also have significant associated cognitive difficulties with working memory, attention, apraxias, fatigue, which may all underlie different ‘aphasic’ symptoms. Having a theoretical understanding of the causes of specific symptoms would appear essential to designing interventions. So the design of studies to examine the effectiveness of interventions becomes even harder.
There is no magical component to aphasia therapy, even to the very best therapy, and aphasia therapists are simply well trained to provide the best treatment they can for aphasic people. That their efforts appear not to produce much more improvement than trained and skilled social interactors may not therefore be such a surprise. Many have suggested that, for the reasons sketched above, not to mention the costs of staging such large projects, single case designs are far more valid and the outcomes more reliable, especially when a series of similar single cases can be evaluated together (6).
1. Kagan, A (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners. Aphasiology, 12, 816-830
2. Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia following stroke. Stroke, 32, 1621-1626.
3. Meinzer, M., Djundja, D., Barthel, G., Elbert, T., & Rockstroh, B. (2005). Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36(7), 1462-1466.
4. Holland, R. & Crinion, J. (2012) Can tDCS enhance treatment of aphasia after stroke? Aphasilogy, Online version: DOI:10.1080/02687038.2011.616925
5. Bhogal, S. K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34, 987–993.
6. Robey, R. R., Schultz, M. C., Crawford, A. B., & Sinner, C. A. (1999). Single-subject clinical-outcome research: Designs, data, effect sizes, and analyses. Aphasiology, 13, 445–473.
Competing interests: I was involved in a competing bid for the same funding to undertake a large multi-centre study of the effectiveness of treatment for aphasia.