Is early speech and language therapy after stroke a waste?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4870 (Published 17 July 2012) Cite this as: BMJ 2012;345:e4870
- 1King’s College London, London SE1 7EH, UK
- 2NIHR Guy’s and St Thomas’ and King’s College London Biomedical Research Centre, London, UK
Research into rehabilitation is a relatively young discipline and there are still few centres of academic excellence in stroke rehabilitation. Randomised trials are difficult to conduct in this area. Large variations in patients and disease characteristics make designing trials tricky; blinding may be difficult; and identifying appropriate control interventions and ensuring that interventions are standardised, especially in multi-site studies, is challenging. However, such problems are not unique to rehabilitation research and can be overcome using complex intervention evaluation methods, as has been shown in other areas of stroke care.1 In a linked research paper (doi:10.1136/bmj.e4407), Bowen and colleagues report the findings of the ACT NoW (Assessing Communication Therapy in the North West) study, which is a large scale multicentre randomised controlled trial of speech and language therapy in the rehabilitation of patients after stroke.2 This study is welcome because, as with other treatment interventions, it is essential that rehabilitation is subjected to rigorous scrutiny.
Single case studies, observational studies, and small single centre randomised trials provide weak evidence for guiding clinicians and planners of care, and they cannot answer fundamental questions about how and what services should be delivered. The direct cost of stroke care, including rehabilitation, in England and Wales is estimated to be £3bn (€3.8bn; $4.7bn) a year.3 The yearly cost of providing occupational therapy and physiotherapy, speech, and language therapy services alone in one 30 bed stroke unit in London, for example, is more than a third of a million pounds. Rehabilitation treatments cannot be assumed to be benign and evidence of their cost effectiveness is needed.
The ACT NoW trial examined outcomes for patients with aphasia or dysarthria in the first four months after stroke. Treatment by a speech and language therapist up to three times a week (using techniques agreed by the speech and language therapy community as being best practice) was compared with a control that comprised similarly resourced social contact (without communication therapy) from employed visitors.
No differences were seen between groups in terms of functional communication at six months as assessed by a blinded independent therapist. Professional speech and language therapy is currently widely provided in stroke rehabilitation services, which makes the findings of the trial highly controversial. They should stimulate an important debate on the way that speech therapy is delivered in the early stages after stroke. It is important to understand the design and conduct of this trial when interpreting its findings and implications for future research and clinical practice. Recruitment to the study was slow and selective, with only 21% of patients with suspected acute onset communication problems being recruited and only 44% of patients who were identified as eligible finally giving consent. There were some protocol violations, particularly in the control group, and more patients without follow-up in the control group. However, the final sample did seem to be representative of the pool of patients presenting to the stroke services. Despite these caveats, for a pragmatic trial of a complex intervention, it was performed well.
The findings do however raise the question of what role, if any, speech and language therapy services should play in early rehabilitation after stroke. About a third of people who have a stroke are likely to be aphasic, and aphasia can have a serious impact on all aspects of patients’ lives and on their carers. Aphasia often negatively affects mood, self image, wellbeing, relationships, employment, and recreational opportunities. Therefore the research question examined by the ACT NoW trial investigators of whether enhanced communication rehabilitation improves speech outcomes if delivered in the first four months after stroke is clearly an important one.
A recent update of the Cochrane review for aphasia after stroke,4 which includes the ACT NoW study, has been published. Most of the studies undertaken thus far, including ACT NoW, have focused on specific interventions aimed at improving deficits in language rather than tackling functional communication through, for example, non-verbal strategies. The Cochrane meta-analysis shows that some form of intervention is better than none, but that no particular intervention is better than another. Accurate diagnosis of the communication disorder is important, at the very least to be able to explain to patients and friends what the problem is and what strategies might be used to aid communication. In specific instances the opinion of an expert in communication disorders will be needed—for example, to help with decisions regarding questions of mental capacity. However, routinely reassessing performance in the early months does not seem to be of benefit. Patients should be encouraged to communicate as much as possible, whether with a therapist or a communication partner. Technologies such as computer programs may be useful.
Recovery of speech after stroke may be prolonged, and communication may still be improving many months and even years after the event. Speech therapy might be more effective if given later. If this is the case, it would be better to reallocate resources away from delivering communication therapy in the acute phase in hospital and sometimes early after discharge to providing more intensive therapy beyond four months.
The ACT NoW trial provides no solutions on how to manage aphasia effectively early after stroke. More focus on the early phase mechanisms that underpin the speech deficit may be needed before further pragmatic trials are undertaken. Although the results do highlight that scarce professional speech and language therapy resources may be inappropriately allocated at present, they do not spell the end of such therapy in the acute phase of stroke rehabilitation.
Cite this as: BMJ 2012;345:e4870
Competing interests: Both authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not peer reviewed.