Title: Listen-In: the development and testing of a web-based therapy application for patients with impaired speech comprehension caused by stroke.
Funder: Department of Health and Social Care

Abstract: Mortality from stroke in the UK has reduced from 21% in 1999 to 12% in 2008. However, stroke prevalence has been increasing, the consequence of socioeconomic and scientific advances that have improved survival; which means that more people are surviving with long-standing disability. Language impairment (aphasia) is the second most common major impairment after stroke, with a prevalence of ~250,000 in the UK. Aphasia may respond to therapy many months and years after the stroke occurs, but provision of specialist therapy (speech and language therapy - SALT) is far below that needed to provide optimal rehabilitation (Code, 2003). We will address this by targeting a common symptom of post-stroke aphasia: impaired speech comprehension. This is particularly important in patients receiving rehabilitation for associated disabilities as poor speech comprehension can impair participation/compliance with treatment programmes (Hilari, 2011, Jette, 2005). Our study is designed to improve speech comprehension in patients with post-stroke aphasia, who are in the chronic phase (>6 months post-stroke). The main aim is to develop and test the clinical efficacy of a novel, web-based, rehabilitation application. Listen-In will provide an effective speech comprehension training tool that patients can use to practice independently. This will free-up SALT time to provide additional assessment, supervision and functional intervention in a highly cost effective manner. See Figure 2 for the three phase plan Phase 1 (24 months. London, Newcastle, Cambridge): Development of Listen-In, including diagnostic and therapeutic components, driven by patient-user's feedback (alpha and beta testing). The intervention is detailed below and is based on current SALT practice. It will be adaptive, provide feedback and target auditory perception at many levels: the phonemic, lexical and sentence level processing of heard verbal stimuli, as well as auditory short term memory and non-verbal sound discrimination. There is no industry standard for defining software milestones. We will pass though the commonly accepted stages: First playable, Alpha, Code freeze and Code release. Phase 2 (12 months. London and Cambridge): A pilot, randomised, cross-over, clinical trial of Listen-In in a group of aphasic patients in the chronic post-stroke period. A power calculation suggests that we will need 36 patents, 18 in each arm. The comparison will be standard SALT clinical care. The main outcome measure is a clinically relevant improvement on the comprehension of spoken language score of the Comprehensive Aphasia Test (Swinburn, 2004). Secondary outcomes include improvements in social activity and participation. The milestones for this phase will be: 50% recruitment into study; and, last-patient, last-visit. Phase 3 (funded outside i4i grant) will be the roll-out of the therapy application on the internet with a pragmatic trial of whether therapy gains can be made outside the confines of a clinical trial. The comparison will be on similar outcome measures as Phase 2 with a control test on sustained attention (internal control) that we predict will not improve with therapy. When we have enough users' data we plan to provide predictions for incoming patients based on their baseline performance, of the form, X number of patients with a similar profile to you practiced this application for Y hours and improved their function by Z." A form of personalized medicine. If Phase 2 is effective, Listen-In will be made available for any suitable NHS patients to use. We will change patients a small fee on a subscription-based model to generate funds to sustain Listen-In. we also plan to make clinical licenses available. The team has the necessary skill mix, experience, project management and infrastructure to successfully carry out this project. Specifically, we have expertise in the design, testing and scientific validation of web-based therapy tools."

Lay abstract: In the last decade or so acute stroke care has improved beyond recognition. Patients, who a few years ago would have died, are now surviving their stroke. This means that the prevalence of people with moderate or severe impairment post-stroke, is increasing. Unfortunately, the investment in acute stroke care has not been matched for those in the intermediate (first year after stroke) and long-term phases. Language disorders (aphasia) are the most feared outcome by patients at risk of stroke (Samsa, 1998) and are the second most common. Comprehension deficits (difficulty understanding what is said to you) are particularly disabling and reduce the chance of patients benefitting from the input of other therapists, e.g.: physiotherapists, occupational therapists (Hilari, 2011, Jette, 2005). Speech and language therapy (SALT) is effective at treating aphasia (Cochrane review: (Brady, 2012)) but the majority of UK patients do not get the correct dose required to improve (Code, 2003). We plan to address this by designing and testing a web-based therapy application called Listen-In that will improve aphasic patients' ability to understand what is being said to them. The study is in three phases and we are asking for i4i funding for the first two: (1) Development of Listen-In, including diagnostic and therapeutic components. Patients with aphasia will inform the design and decide when the product is ready. (2) Test the effectiveness of Listen-In in the context of a pilot, randomized, cross-over clinical trial comparing Listen-In with standard clinical care (locally provided SALT). (3) If Listen-In is effective, we will test its roll-out on the internet with a pragmatic trial (University funded). This will be a multi-center study with centers in London, Cambridge and Newcastle. This will maximize the probability that the therapy application will be acceptable to all future English-speaking patients who stand to benefit.

Research activity codes: 6.7 PHYSICAL;5.7 PHYSICAL
Health categories: STROKE