Evidence
Alert

Intensive speech therapy helps stroke survivors with persistent communication difficulties

Intensive speech and language therapy begun six months or more after a stroke improved verbal communication, language comprehension and self-reported quality of life for those with persistent communication difficulties (chronic aphasia).

The therapy in this trial consisted of around 30 hours over three weeks. Participants who received low-intensity therapy (around one hour per week) whilst on a waiting list did not improve during that time. NICE guidelines recommend speech and language therapy immediately after a stroke and if the person still experiences communication difficulties six months after their stroke, but do not specify the intensity of the therapy.

This trial highlights the modest benefits of providing further intensive speech and language therapy for stroke survivors who continue to have aphasia after six months. The Royal College of Speech and Language Therapists previously raised concerns about lack of access to this type of therapy. However before implementation it will be important to know which component of therapy is providing the benefits and how much it costs compared to alternatives.

Why was this study needed?

As treatment of strokes improves there are increasing numbers of stroke survivors requiring help and support to enable them to live their life to the fullest. A third of the UK’s 1.1 million stroke survivors experience communication difficulties.

Aphasia affects how people choose which words to use and combine them into sentences, affecting both speech and writing. People with aphasia can also experience difficulties in understanding words and sentences. Depression is common after stroke and could be worsened by an inability to communicate.

Speech and language therapy can help people with aphasia to communicate more effectively. There have been randomised controlled trials investigating its effectiveness, but these have generally been small, short and of low methodological quality. This limits our confidence in their findings.

This randomised controlled trial investigated the effectiveness of intensive speech and language therapy in people who still had aphasia six months or more after a stroke.

What did this study do?

The FCET2EC (From Controlled Experimental Trial 2 Everyday Communication) trial randomly allocated 156 German people with chronic aphasia to immediately receive intensive speech and language therapy, or stay on a waiting list for three weeks before receiving therapy. Participants had an average age of 53 and the stroke had occurred between one and six years previously.

The intensive therapy intervention took place over three weeks. Each group had one-to-one sessions (22 hours), group therapy (nine hours) and self-led exercises (15 hours). Over 90% of participants continued with one hour of therapy per week in the six month follow-up.

This was a well-designed trial with reliable results. However, it did not consider cost effectiveness and the therapy is more intensive than current NHS speech and language therapy.

What did it find?

  • Average scores for the effectiveness of verbal communication were higher after three weeks of intensive therapy. Using the ANELT A-scale, a 50 point scoring system where higher scores are better, intensive therapy increased the score by 2.61 points to 31.39 compared to no change for people on the waiting list. A one point improvement could mean going from not being able to communicate at all to having basic communication capabilities.
  • Compared to people on the waiting list, people who received therapy had moderately higher scores in linguistic tests – including language comprehension and production (effect size 0.73). People who received therapy also better self-reported quality of life (effect size 0.27).
  • Three weeks after each group had received intensive therapy, 44% of people had an improvement of at least three points in verbal communication.

What does current guidance say on this issue?

Following a stroke, NICE recommends that people are screened for communication difficulties within 72 hours and referred for speech and language therapy if needed. Individuals can be re-referred if communication difficulties persist six months after their stroke.

Speech and language therapy aims to enable the person to make the most of their communication abilities, teaching other communication methods (gestures, writing, using props) and coaching people around them (such as family members) to help maximise their communication potential. This helps the individual to adjust to their communication impairment, build their confidence and rebuild their identity to participate in everyday life.

What are the implications?

Speech and language therapy has generally been considered most effective in the six months following a stroke. However, this trial suggests that intensive therapy can modestly improve the communication capabilities and quality of life of people with chronic aphasia if begun six months or more after their stroke.

The control participants who received low-intensity therapy whilst on a waiting list did not improve, suggesting that the intensity or time spent in therapy impacts on its effectiveness.

The resource availability and its cost may limit the ability of the NHS to offer high intensity therapy, but this new evidence alongside further evaluation of the costs and intensity required could contribute to the case for making this sort of therapy more widely available.

 

Citation and Funding

Breitenstein C, Grewe T, Flöel A, et al; FCET2EC study group. Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. Lancet. 2017;389(10078):1528-38.

This trial was funded by the German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

 

Bibliography

NHS Choices. Aphasia. London: Department of Health; 2015.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

RCSLT. Supporting stroke survivors. London: Royal College of Speech and Language Therapists.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

Commentaries

Expert commentary

Imagine suddenly losing the ability to communicate your thoughts and feelings, or to understand what you hear or read. This is aphasia and it happens to many stroke survivors. Now imagine being told your chances of recovery will “plateau” after six months and therapy is pointless. This important study ends that nihilism. People with chronic aphasia can benefit from support and improve their everyday communication.

To change practice we next need to find out whether this benefit is due to general language stimulation or psychological well-being from spending time with a caring professional, or if it requires the specific therapy.

Audrey Bowen, Stroke Association John Marshall Memorial Professor of Neuropsychological Rehabilitation