Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

With great interest we have read the report of the scrupulously designed study by Bowen and colleagues. We laud their complex trial design with which they have studied not only the effectiveness of speech and language therapy for patients with various communication deficits after stroke, but also the cost effectiveness of speech and language therapy and conducted a qualitative study of experiences in patients and their proxies with the provided intervention. We feel however that the authors jump to a conclusion by claiming that speech and language therapy might be discarded in the early stage of recovery after stroke.

The recently updated Cochrane review concludes that language therapy is more effective if it is provided intensively (2). Hów intensive however is still unclear. Bowen et al report that the intervention group on average received 22 contacts (18 hours) over 13 weeks, which comes down to a little over 1,5 hours of therapy per week. Only 53% of this time was spent on direct one-to-one contacts (including assessments) and half of this limited time consisted of impairment based therapy. Several studies suggest a minimally required treatment intensity of two hours per week to add an effect of therapy to spontaneous recovery (3-6). Hence, the impairment-based treatment delivered in the ACT NoW study was probably not sufficiently intensive to generate an additional effect.

Prof. Code already questioned whether the contrast between the two interventions; SLT with a professional versus AC with a trained visitor, was substantial enough. From this point of view it is interesting to note that even with such a small treatment contrast, the 95% confidence interval of the primary effect measure included the clinically worthwhile difference of 0.5 points on the TOM, and cannot be used to rule out a treatment effect.

We entirely agree with dr. Meteyard that it is peculiar to combine aphasia and dysarthria to one population of patients with communication deficits. Prof. Code emphasizes that a population of aphasic patients alone is highly heterogeneous and challenges researchers to design proper studies. Adding another impairment increases heterogeneity even more, hampering correct interpretation of Bowens’ findings.

Bowen et al timed their primary outcome at six months after stroke. Agreed, this is an important time, because spontaneous recovery should have occurred already and patients now enter the chronic stage. However, in the absence of earlier follow-up measurements, we are not informed about recovery processes in both groups during the first six months. We wonder if recovery is equal in both groups or if one group reached better communication skills earlier, which is not a negligible benefit of treatment.

In our opinion there is a need for further trials of SLT with a strong intervention contrast and proper evaluation. We are conducting a multi centre RCT in the Netherlands on early intensive cognitive-linguistic language treatment (CLT) in aphasia after stroke, called “Rotterdam Aphasia Therapy Study (RATS) – 3; The efficacy of cognitive-linguistic therapy in the acute stage of aphasia: a randomised controlled trial”. We will randomise 150 patients with first ever aphasia after stroke within two weeks post stroke for either the therapy group (four weeks of intensive, one hour a day CLT) or the control group (in which regular language therapy is deferred for four weeks). Both groups continue with regular, less intensive, language therapy after these four weeks.
We chose three evaluation moments; directly after four weeks of either intensive therapy or no therapy and three and six months after inclusion. This design allows us to evaluate if there is a direct treatment effect of early intensive CLT (results after four weeks), and whether this supposed effect lasts beyond the acute phase (results after three and six months). The trial design is summarised in the Dutch Trial Register (www.trialregister.nl, NTR3271) and will be published later this year.

In conclusion, we agree with Prof. Enderby, Dr. Meteyard and Prof. Code that it is not possible to conclude from the ACT NoW study that speech and language therapy is equally effective as no therapy. In our opinion, further research is needed to establish the optimal timing and treatment intensity of speech and language therapy for patients with aphasia due to stroke.

On behalf of the Department of Neurology, Erasmus Medical Centre:

F. Nouwens MA, speech and language therapist and clinical linguist
Dr. L.M.L. de Lau, neurologist
Dr. E.G. Visch-Brink, clinical linguist
Prof. Dr. D.W.J. Dippel, neurologist

Correspondence to:
F. Nouwens, MA
Erasmus Medical Centre, Department of Neurology
Office Ee 2291
P.O. Box 2040
3000 CA Rotterdam
The Netherlands
f.nouwens@erasmusmc.nl

References

1. Bowen A, Hesketh A, Patchick E, Young A, Davies L, Vail A, et al. Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ. 2012;345:e4407.
2. Brady MC, Kelly H, Godwin J, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2012;5:CD000425.
3. Robey RR. A meta-analysis of clinical outcomes in the treatment of aphasia. J Speech Lang Hear Res. 1998 Feb;41(1):172-87.
4. Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke. 2003 Apr;34(4):987-93.
5. Salter K, Teasell R, Bhogall S, al e. Evidence-based review of stroke rehabilitation: Aphasia: V.11 2007: Available from: http://www.ebrsr.com.
6. Bakheit AM, Shaw S, Barrett L, Wood J, Carrington S, Griffiths S, et al. A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clin Rehabil. 2007 Oct;21(10):885-94.