Rehabilitation and recovery – communication and language

A high quality meta-analysis carried out by the RELEASE Collaborators (2022b) re-examined data from 25 published trials involving 959 people with aphasia across 10 different languages. This meta-analysis demonstrated a clear dose effect (total hours of therapy); that is, people with aphasia who received more hours of therapy (more than 20 to 50 hours) made large and clinically meaningful gains in language abilities and function, compared with those who received fewer hours. No functional communication gains were observed for people with aphasia receiving less than 5 hours of therapy nor comprehension gains for those receiving less than 20 hours. There was a weaker effect of frequency (number of days per week that therapy was delivered) with 3-5 days being best. The data on intensity (hours of therapy per week) were less clear (Dignam et al, 2015; RELEASE Collaborators, 2022a). [2023]

The majority of evidence derives from people with aphasia in the chronic phase (more than 6 months after stroke but often much longer than this). There is no evidence to support a set time limit after stroke when therapy should be stopped. People with aphasia should be offered therapy for as long as they continue to make meaningful gains in their language and communication abilities (RELEASE Collaborators, 2021). [2023]

The greatest overall gains in language outcomes for people with aphasia after stroke are seen when therapy starts in the acute/subacute stage, within 1 month of stroke (RELEASE Collaborators, 2021). There is less evidence regarding the intensity and dose for people with aphasia when treatment starts within one month of stroke. A high quality RCT of people with acute stroke showed no difference between 10 hours (control group) and 23 hours (active group) of speech and language therapy delivered over a month (Godecke et al, 2021). [2023]

For people with aphasia in the chronic phase (more than 3 months after stroke) the greatest gains were associated with moderate-intensity/high-dose therapy (3-4 hours/week; more than 50 hours of treatment in total; (RELEASE Collaborators, 2022b)). One way of delivering higher doses of therapy is through comprehensive aphasia programmes, with positive results seen in one non-randomised trial (Hoover et al, 2017) and one observational study (Leff et al, 2021). However, not all people with aphasia can manage the high-intensity treatment mandated by these programmes. These studies suffer from selection bias and their results cannot be generalised to all people with aphasia, and more high quality research is needed. [2023]

There has been a lot of interest in digital therapies for people with aphasia, with several RCTs demonstrating large gains in naming in particular (Palmer et al, 2019; Braley et al, 2021). It should be noted that the majority of digital therapies are not designed to replicate the interventions delivered by a speech and language therapist – rather, they automate the repetitive and often impairment-based aspects of therapy. As such, their effects are often only seen on the aspects of language, or items, that the person with aphasia practices. There is good evidence that both clinician and self-administered digital therapies can be effective (Lavoie et al, 2017), but those with more support from carers or therapists tend to engage more and make larger language gains (Harrison et al, 2020). [2023]

Stroke services should consider all the ways that the dose of speech and language therapy can be increased to the levels recommended here, as they are considerably higher than currently delivered. Holistic aspects of rehabilitation such as peer support, social and singing groups may have communication benefits as they provide opportunity for social communication practice.  Groups or programmes (such as return to work) should be facilitated and adapted to ensure accessibility for those with aphasia.  Aphasia-specific participation activities, such as with communication partners from the statutory or voluntary sectors, should be available, together with equipment and training for supervised telerehabilitation. [2023]

There are only two small RCTs on this topic, neither of which provides definitive evidence regarding treatment. Bowen et al (2012) included a planned subgroup of 66 people with dysarthria and Mackenzie et al (2014) was a feasibility study of 39 people. In the former, there was no significant difference between speech and language therapy and an attention control in the first few months after stroke, but a nested, qualitative study found that early, regular and frequent contact from a therapist or trained visitor was positively rated by people with stroke and their family/carers (Young et al, 2013). Mackenzie et al (2014) involved people with chronic dysarthria, and there was no difference in outcomes between individuals who received only speech practice and those who received speech practice and oro-motor exercises, although both groups improved over time. Participants were compliant with both interventions and many completed daily independent practice and reported an increase in confidence with treatment. There is little evidence to support the interventions in common use but there is some evidence of qualitative benefits (Palmer & Enderby, 2007). [2016]

Studies in apraxia of speech are often small a Cochrane review (West et al, 2005) found no trials. There has been one subsequent crossover trial (Varley et al, 2016) which compared self-administered computerised communication therapy with a sham computerised treatment for people with chronic speech apraxia. Improvements in spoken word production (naming and repetition) were greater for the intervention group after the six week treatment but limited to trained single words. [2016]