Computerised speech and language therapy in post-stroke aphasia
Authors: Agnes Flöel
Journal: The Lancet Neurology (2019)

Cerebrovascular diseases are among the most common causes of disability worldwide. Around one third of stroke survivors initially have aphasia,1Engelter ST Gostynski M Papa S et al.Epidemiology of aphasia attributable to first ischemic stroke: incidence, severity, fluency, etiology, and thrombolysis.Stroke. 2006; 37: 1379-1384Crossref PubMed Scopus (370) Google Scholar and symptoms of aphasia persist in up to 40% of these patients.2Doesborgh SJ van de Sandt-Koenderman MV Dippel DW van Harskamp F Koudstaal PJ Visch-Brink EG Effects of semantic treatment on verbal communication and linguistic processing in aphasia after stroke: a randomized controlled trial.Stroke. 2004; 35: 141-146Crossref PubMed Scopus (98) Google Scholar Importantly, chronic post-stroke aphasia affects vocational reintegration, social life, and emotional wellbeing, while placing major burdens on the health-care system.3Ellis C Simpson AN Bonilha H Mauldinn PD Simpson KN The one-year attributable cost of poststroke aphasia.Stroke. 2012; 43: 1429-1431Crossref PubMed Scopus (74) Google Scholar In The Lancet Neurology, Rebecca Palmer and colleagues4Palmer 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 Neurology. 2019; 18: 821-833Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar report the results of a multicentre, single-blinded, randomised controlled trial assessing the effectiveness of three interventions, each with a 6-month duration, in 240 patients with aphasia more than 4 months after stroke. The interventions were: usual care combined with daily, self-managed, computerised speech and language therapy (CSLT); usual care combined with attention control, and usual care alone. Compared with the other interventions, CSLT resulted in clinically significant gains in retrieving personally relevant words. However, this progress did not translate into improved conversational ability, nor did it benefit the participants' perception of communication performance, social participation, or quality of life. Similarly, health economics evaluation suggested that CSLT intervention is unlikely to be cost-effective for the whole population with aphasia. The strengths of this trial include a high-quality methodological approach, generalisability due to its naturalistic setting, and representative recruitment of patients from the clinical population, along with a broad range of outcome measures assessing impairment severity (naming ability), communicative function (conversational ability), and social participation (quality of life). The implicit assumption about gains in word retrieval through naming training—as shown in the trial by Palmer and colleagues—has often been that these gains will translate into improvements in conversation automatically, and that the increased use of personally relevant words will improve patients' quality of life. Given that self-administered CSLT offers a low-cost and widely available approach to training, this method might be more compatible with demands of health-care policy makers and insurance companies than face-to-face interventions, when considering economic constraints and shortages in staff delivering the treatment. However, Palmer and colleagues have now clearly shown that these assumptions are incorrect: irrespective of progress in retrieval of personally relevant words, communicative function and social participation did not improve, nor did the intervention increase the patients' quality of life or reduce costs. In contrast, a high-quality randomised controlled trial5Breitenstein C Grewe T Floel A et al.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: 1528-1538Summary Full Text Full Text PDF PubMed Scopus (112) Google Scholar of 156 patients with chronic post-stroke aphasia has shown that, compared with standard care, a mix of cognitive and linguistic approaches, communicative and pragmatic therapy, and computerised training can improve symptoms in patients with chronic post-stroke aphasia, as revealed by outcomes assessing communicative function, including the Amsterdam-Nijmegen Everyday Language Test (ANELT). Similarly, a further trial6Meinzer M Darkow R Lindenberg R Floel A Electrical stimulation of the motor cortex enhances treatment outcome in post-stroke aphasia.Brain. 2016; 139: 1152-1163Crossref PubMed Scopus (92) Google Scholar of 26 patients with chronic post-stroke aphasia provides evidence that intensive naming therapy combined with training-adjuvant interventions—such as non-invasive brain stimulation—leads to improved scores on outcomes reflecting communicative function (eg, Communicative Effective Index or Partner Communicative Questionnaire). It is worth noting that computerised forms of intensive speech and language therapy are not necessarily confined to naming of objects shown on the screen; rather, they might be applicable as well for communicative and pragmatic methods7Stahl B Mohr B Dreyer FR Lucchese G Pulvermüller F Using language for social interaction: Communication mechanisms promote recovery from chronic non-fluent aphasia.Cortex. 2016; 85: 90-99Crossref PubMed Scopus (29) Google Scholar alongside non-invasive brain stimulation8Floel A tDCS-enhanced motor and cognitive function in neurological diseases.Neuroimage. 2014; 85: 934-947Crossref PubMed Scopus (232) Google Scholar to enhance conversational ability. Hence, attempts to develop innovative techniques of CSLT seem to be justified. Moreover, treatment intensity in Palmer and colleagues' trial, even in the CSLT group, was less than the currently recommended dose of speech and language therapy (5 h per week),9Brady MC Kelly H Godwin J Enderby P Campbell R Speech and language therapy for aphasia following stroke.Cochrane Database Syst Rev. 2016; 6CD000425Google Scholar which might have also contributed to the absence of progress in conversational ability. Future studies should use outcome measures with validated sensitivity to treatment-induced changes (eg, ANELT as part of a core outcome set defined in an international consensus statement).10Wallace SJ Worrall L Rose T et al.A core outcome set for aphasia treatment research: the ROMA consensus statement.Int J Stroke. 2019; 14: 180-185Crossref PubMed Scopus (46) Google Scholar A randomised controlled trial combining an adaptive version of computerised intensive naming therapy (10 h per week), communicative and pragmatic therapy, and non-invasive brain stimulation is underway (NCT03930121). In the event of significantly higher increase in the primary outcome (ANELT) in the therapy plus stimulation condition, as compared with the therapy plus placebo condition, this trial would show clinically significant gains in conversational ability. In summary, computerised forms of speech-language therapy can be recommended as an add-on strategy; however, they should not be the sole means of treatment for individuals with aphasia—at least not now. Combining traditional face-to-face speech and language therapy with new approaches, including non-invasive brain stimulation, might promote recovery of language function and, just as importantly, increase quality of life. Rather than serving as a low-cost alternative to traditional face-to-face speech and language therapy, future computerised rehabilitation methods will hopefully advance the effectiveness of established programmes in the treatment of patients with chronic post-stroke aphasia. I declare no competing interests. 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 trialCSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. Full-Text PDF Open Access