Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis
Creators: name: Brady, MC
name: Ali, M
name: VandenBerg, K
name: Williams, LJ
name: Williams, LR
name: Abo, M
name: Becker, F
name: Bowen, A
name: Brandenburg, C
name: Breitenstein, C
name: Bruehl, S
name: Copland, DA
name: Cranfill, TB
name: Pietro-Bachmann, MD
name: Enderby, P
name: Fillingham, J
name: Galli, F Lucia
name: Gandolfi, M
name: Glize, B
name: Godecke, E
name: Hawkins, N
name: Hilari, K
name: Hinckley, J
name: Horton, S
name: Howard, D
name: Jaecks, P
name: Jefferies, E
name: Jesus, LMT
name: Kambanaros, M
name: Kang, E Kyoung
name: Khedr, EM
name: Kong, A Pak-Hin
name: Kukkonen, T
name: Laganaro, M
name: Ralph, MA Lambon
name: Laska, A Charlotte
name: Leemann, B
name: Leff, AP
name: Lima, RR
name: Lorenz, A
name: MacWhinney, B
name: Marshall, R Shisler
name: Mattioli, F
name: Maviş, İ
name: Meinzer, M
name: Nilipour, R
name: Noé, E
name: Paik, NJ
name: Palmer, R
name: Papathanasiou, I
name: Patricio, B
name: Martins, I Pavão
name: Price, C
name: Jakovac, T Prizl
name: Rochon, E
name: Rose, Miranda
name: Rosso, C
name: Rubi-Fessen, I
name: Ruiter, MB
name: Snell, C
name: Stahl, B
name: Szaflarski, JP
name: Thomas, SA
name: van de Sandt-Koenderman, M
name: van der Meulen, I
name: Visch-Brink, E
name: Worrall, L
name: Wright, H Harris
Publisher: name: La Trobe
Year: 2023
Subjects: classificationCode: 3209
subject: Neurosciences
subject: FOS: Clinical medicine
classificationCode: 4201
subject: Allied health and rehabilitation science

description: Background: Stroke rehabilitation interventions are routinely personalized to address individuals’ needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias. Aim: We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database. Methods: MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/&gt; 65 years), aphasia severity (mild–moderate/ moderate–severe based on language outcomes’ median value), chronicity (⩽/&gt; 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (&gt; 50%), results were reported for completeness. Results: 959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension &gt; 9 h/week); older participants’ greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (&gt; 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those &gt; 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3–4 SLT-h/week; ⩾ 50 hours). For moderate–severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild–moderate participants’ greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males’ greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (&gt; 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (&lt; 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT &gt; 9 h over ⩾ 4 days/week. Conclusions: We observed a treatment response in most subgroups’ overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild–moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate–severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.