People with aphasia caused by a stroke show improvements in retrieving words when they use self-managed computerised speech and language therapy in addition to usual care from a speech and language therapist. No improvements are seen in patients’ conversational abilities or their quality of life.
Aphasia is a complex language and communication disorder. It can affect people’s abilities to read, listen, speak, and write or type. Symptoms vary: some people may mix up a few words, while others have problems with all communication. Speech and language therapists work with patients and their carers to help them improve their speech and use alternative ways of communicating, but there is a shortage of therapists.
This well-conducted NIHR-funded trial shows that adding computerised speech and language therapy to usual care can have some benefits, and is a relatively low-cost intervention. It also highlights areas for further research.
Why was this study needed?
Aphasia is usually caused by damage to the left side of the brain, most commonly after a stroke. Around 110,000 people in England have a stroke each year. About a third of survivors will have aphasia. Between 30% and 43% of those affected have symptoms in the long term.
Most people make some improvement with speech and language therapy, and some people recover fully. However, speech and language therapy is resource-intensive and difficult to obtain in the NHS. Some small studies have suggested that computerised therapy might be an effective way to provide additional therapy for those who need it. Computer programmes allow patients to complete exercises to help with word-retrieval and other language problems. They can be tailored for individuals and are readily available.
This study aimed to assess the clinical and cost-effectiveness of self-managed computer speech and language therapy used in addition to usual care.
What did this study do?
Big CACTUS was a randomised controlled trial that recruited 278 adults with aphasia from 20 NHS trusts in the UK.
Participants were randomly assigned to one of three groups. The ‘usual care’ group received support from a speech and language therapist. The ‘computerised speech and language therapy’ group had usual care plus six months of using a computer programme daily at home. This was a self-managed set of word-finding exercises, tailored for each individual. There was also an ‘attention control’ group, who received usual care in addition to completing paper-based puzzle book activities (such as Sudoku, or word searches) daily for six months. This last group helped to ensure that any effect could be attributed to the computer intervention rather than just increased attention from a therapist.
This was a robust, albeit relatively small trial, but it was limited to English speakers, as the computer programme was only available in English.
What did it find?
- On average, participants in the group using a computer had improved word finding of 16.2% more than those in the usual care group (95% confidence interval [CI] 12.7 to 19.6), and 14.4% more than those in the attention control group (95% CI 10.8 to 18.1). This was greater than the pre-specified clinically important difference of 10%. This improvement was maintained at 9 and 12 months.
- The computer therapy did not improve functional communication. Nor did it have an impact on participants’ own perceptions of their communication, social participation or quality of life.
- The mean cost per person for the computer therapy was £733. The cost for the equivalent amount of face-to-face time with a speech and language therapist would be approximately £1,400.
What does current guidance say on this issue?
NICE published guidance on stroke rehabilitation in adults in 2013. Its section on communication states that speech and language therapists should provide direct impairment-based therapy for communication impairments such as aphasia. It doesn’t specify what that therapy should be, or how it should be delivered.
The Royal College of Speech and Language Therapists resource manual for commissioning and planning services for aphasia states that computer-based therapy directed by a speech and language therapist is beneficial, cost-effective and acceptable.
What are the implications?
This study shows that self-managed computerised speech and language therapy can be used alongside usual care to improve patients’ ability to retrieve words. Costs come mainly from the time spent by speech and language therapists setting up the software and providing technical support. This could be done by therapy assistants, which would reduce costs.
However, the benefit was limited to word-finding. It did not improve conversation or quality of life. More research is needed to identify ways of helping patients in these areas. In addition, researchers could evaluate other computer programmes. Programmes in languages other than English might also be worth researching further.
Citation and Funding
Palmer R, Dimairo M, Cooper C et al. Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial. Lancet Neurol. 2019;18:821-33.
This project was funded by the NIHR Health Technology Assessment Programme (project number 12/21/01) and the Tavistock Trust for Aphasia.
Brady MC, Kelly H, Godwin J et al. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2016;(6):CD000425.
NHS website. Aphasia. London: Department of Health and Social Care; updated 2018.
NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.
RCSLT. RCSLT resource manual for commissioning and planning services for SLCN: aphasia. London: Royal College of Speech and Language Therapists; 2009 (updated 2014).
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