Complex speech-language therapy interventions for stroke-related aphasia: the RELEASE study incorporating a systematic review and individual participant data network meta-analysis
Health and Social Care Delivery Research, vol. 10, pp. 1–272
Abstract
Background People with language problems following stroke (aphasia) benefit from speech and language therapy. Optimising speech and language therapy for aphasia recovery is a research priority. Objectives The objectives were to explore patterns and predictors of language and communication recovery, optimum speech and language therapy intervention provision, and whether or not effectiveness varies by participant subgroup or language domain. Design This research comprised a systematic review, a meta-analysis and a network meta-analysis of individual participant data. Setting Participant data were collected in research and clinical settings. Interventions The intervention under investigation was speech and language therapy for aphasia after stroke. Main outcome measures The main outcome measures were absolute changes in language scores from baseline on overall language ability, auditory comprehension, spoken language, reading comprehension, writing and functional communication. Data sources and participants Electronic databases were systematically searched, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Linguistic and Language Behavior Abstracts and SpeechBITE (searched from inception to 2015). The results were screened for eligibility, and published and unpublished data sets (randomised controlled trials, non-randomised controlled trials, cohort studies, case series, registries) with at least 10 individual participant data reporting aphasia duration and severity were identified. Existing collaborators and primary researchers named in identified records were invited to contribute electronic data sets. Individual participant data in the public domain were extracted. Review methods Data on demographics, speech and language therapy interventions, outcomes and quality criteria were independently extracted by two reviewers, or available as individual participant data data sets. Meta-analysis and network meta-analysis were used to generate hypotheses. Results We retrieved 5928 individual participant data from 174 data sets across 28 countries, comprising 75 electronic (3940 individual participant data), 47 randomised controlled trial (1778 individual participant data) and 91 speech and language therapy intervention (2746 individual participant data) data sets. The median participant age was 63 years (interquartile range 53–72 years). We identified 53 unavailable, but potentially eligible, randomised controlled trials (46 of these appeared to include speech and language therapy). Relevant individual participant data were filtered into each analysis. Statistically significant predictors of recovery included age (functional communication, individual participant data: 532, n = 14 randomised controlled trials) and sex (overall language ability, individual participant data: 482, n = 11 randomised controlled trials; functional communication, individual participant data: 532, n = 14 randomised controlled trials). Older age and being a longer time since aphasia onset predicted poorer recovery. A negative relationship between baseline severity score and change from baseline ( p < 0.0001) may reflect the reduced improvement possible from high baseline scores. The frequency, duration, intensity and dosage of speech and language therapy were variously associated with auditory comprehension, naming and functional communication recovery. There were insufficient data to examine spontaneous recovery. The greatest overall gains in language ability [14.95 points (95% confidence interval 8.7 to 21.2 points) on the Western Aphasia Battery-Aphasia Quotient] and functional communication [0.78 points (95% confidence interval 0.48 to 1.1 points) on the Aachen Aphasia Test-Spontaneous Communication] were associated with receiving speech and language therapy 4 to 5 days weekly; for auditory comprehension [5.86 points (95% confidence interval 1.6 to 10.0 points) on the Aachen Aphasia Test-Token Test], the greatest gains were associated with receiving speech and language therapy 3 to 4 days weekly. The greatest overall gains in language ability [15.9 points (95% confidence interval 8.0 to 23.6 points) on the Western Aphasia Battery-Aphasia Quotient] and functional communication [0.77 points (95% confidence interval 0.36 to 1.2 points) on the Aachen Aphasia Test-Spontaneous Communication] were associated with speech and language therapy participation from 2 to 4 (and more than 9) hours weekly, whereas the highest auditory comprehension gains [7.3 points (95% confidence interval 4.1 to 10.5 points) on the Aachen Aphasia Test-Token Test] were associated with speech and language therapy participation in excess of 9 hours weekly (with similar gains notes for 4 hours weekly). While clinically similar gains were made alongside different speech and language therapy intensities, the greatest overall gains in language ability [18.37 points (95% confidence interval 10.58 to 26.16 points) on the Western Aphasia Battery-Aphasia Quotient] and auditory comprehension [5.23 points (95% confidence interval 1.51 to 8.95 points) on the Aachen Aphasia Test-Token Test] were associated with 20–50 hours of speech and language therapy. Network meta-analyses on naming and the duration of speech and language therapy interventions across language outcomes were unstable. Relative variance was acceptable (< 30%). Subgroups may benefit from specific interventions. Limitations Data sets were graded as being at a low risk of bias but were predominantly based on highly selected research participants, assessments and interventions, thereby limiting generalisability. Conclusions Frequency, intensity and dosage were associated with language gains from baseline, but varied by domain and subgroup. Future work These exploratory findings require confirmatory study designs to test the hypotheses generated and to develop more tailored speech and language therapy interventions. Study registration This study is registered as PROSPERO CRD42018110947. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research ; Vol. 10, No. 28. See the NIHR Journals Library website for further project information. Funding was also provided by The Tavistock Trust for Aphasia.
Authors 68
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Affiliation as printed
Nursing Midwifery and Allied Health Professions Unit, Glasgow Caledonian University, Glasgow, UK
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Nursing Midwifery and Allied Health Professions Unit, Glasgow Caledonian University, Glasgow, UK
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Nursing Midwifery and Allied Health Professions Unit, Glasgow Caledonian University, Glasgow, UK
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Glasgow Caledonian University · University of Edinburgh
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Nursing Midwifery and Allied Health Professions Unit, Glasgow Caledonian University, Glasgow, UK
The Usher Institute, University of Edinburgh, Edinburgh, UK
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Glasgow Caledonian University · University of Edinburgh
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Nursing Midwifery and Allied Health Professions Unit, Glasgow Caledonian University, Glasgow, UK
The Usher Institute, University of Edinburgh, Edinburgh, UK
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Jikei University School of Medicine
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Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
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University of Oslo · Sunnaas sykehus
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Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
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Manchester Academic Health Science Centre · University of Manchester
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Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
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School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
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Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Stefanie Bruehl Aachen Clinical and Cognitive Neurosciences Department of Neurology, Medical Faculty
University of Manchester · St. Mauritius Therapieklinik · RWTH Aachen University
Affiliation as printed
Clinical and Cognitive Neurosciences, Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
St Mauritius Rehabilitation Centre, Meerbusch, Germany
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School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
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Special Education, Eastern Kentucky University, Richmond, KY, USA
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University of Geneva · University Hospital of Geneva
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Division of Neurorehabilitation, Department of Clinical Neurosciences, University Hospitals and University of Geneva, Geneva, Switzerland
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School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Nursing Directorate, NHS Improvement, London, UK
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Marche Polytechnic University · Azienda Ospedaliero-Universitaria delle Marche
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Neurorehabilitation Clinic, Neurological Sciences Department, Marche Polytechnic University, Ospedali Riuniti di Ancona, Ancona, Italy
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Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Université de Bordeaux · Centre Hospitalier Universitaire de Bordeaux
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Department of Physical Medicine and Rehabilitation, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
EA 4136 Handicap Activity Cognition Health, University of Bordeaux, Bordeaux, France
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School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
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Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
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University of London · City, University of London
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Division of Language and Communication Science, City, University of London, London, UK
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Nova Southeastern University, Fort Lauderdale, FL, USA
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School of Health Sciences, University of East Anglia, Norwich, UK
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School of Education Communication and Language Sciences, Newcastle University, Newcastle Upon Tyne, UK
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Faculty of Linguistics and Literary Studies, Bielefeld University, Bielefeld, Germany
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Department of Psychology, University of York, York, UK
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School of Health Sciences (ESSUA) and Institute of Electronics and Informatics Engineering of Aveiro (IEETA), University of Aveiro, Aveiro, Portugal
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Cyprus University of Technology
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Department of Rehabilitation Sciences, Cyprus University of Technology, Limassol, Cyprus
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Kangwon National University Hospital
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Department of Rehabilitation Medicine, Kangwon National University Hospital, Gangwon-do, Republic of Korea
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Assiut University Hospitals · Assiut University
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Department of Neurology, Assiut University Hospital, Assiut, Egypt
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School of Communication Sciences and Disorders, University of Central Florida, Orlando, FL, USA
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Ear, Nose and Throat (ENT)/Department of Phoniatry, Tampere University Hospital, Tampere, Finland
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Faculty of Psychology and Educational Science, University of Geneva, Geneva, Switzerland
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MRC Cognition and Brain Sciences Unit · University of Cambridge · Medical Research Council
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Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
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Danderyds sjukhus · Karolinska Institutet
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Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Neurorééducation, Département des Neurosciences Cliniques, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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UCL Queen Square Institute of Neurology · University College London
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Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
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Department of Speech Language Pathology, Educational Association Bom Jesus – IELUSC, Santa Catarina, Brazil
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Humboldt-Universität zu Berlin
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Institut für Psychologie, Humboldt University Berlin, Berlin, Germany
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Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
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Department of Communication Sciences and Special Education, University of Georgia, Athens, GA, USA
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The University of Queensland · Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia
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Neuropsychology Unit, Azienda Socio Sanitaria Territoriale (ASST), Brescia via Nikolajewka 13, Italy
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
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Department of Speech and Language Therapy, Anadolu University, Eskişehir, Turkey
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UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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University of Social Welfare and Rehabilitation Sciences
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Department of Speech Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
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NEURORHB-Hospitales Vithas, Valencia, Spain
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Seoul National University · Seoul National University Bundang Hospital
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Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Technological Educational Institute of Western Greece
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Department of Speech and Language Therapy, Technological Educational Institute of Western Greece, Patras, Greece
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Universidade do Porto · Universidade Técnica do Porto
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Speech Therapy Department of Health School of Polytechnic Institute of Porto, Porto, Portugal
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Laboratório de Estudos de Linguagem, Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisbon, Portugal
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Wellcome Centre for Human Neuroimaging · University College London
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Wellcome Centre for Human Neuroimaging, University College London, London, UK
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Department of Speech and Language Pathology, Faculty of Education and Rehabilitation Sciences, University of Zagreb, Zagreb, Croatia
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University of Toronto · Toronto Rehabilitation Institute
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Department of Speech–Language Pathology and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
Toronto Rehabilitation Institute, Toronto, ON, Canada
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Centre of Research Excellence in Aphasia Recovery and Rehabilitation, La Trobe University, Melbourne, VIC, Australia
School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia
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Centre National de la Recherche Scientifique · Inserm · Sorbonne Université · Assistance Publique – Hôpitaux de Paris · Institut du Cerveau
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Institut du Cerveau (Paris Brain Institute), Sorbonne Université, ICM, Inserm, CNRS, AP-HP, Hôpital Salpetriere, Stroke Unit, DMU Neuroscience 6, Paris, France
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RehaNova Rehabilitation Hospital and Department of Special Education and Rehabilitation, University of Cologne, Cologne, Germany
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Radboud University Nijmegen · Sint Maartenskliniek
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Sint Maartenskliniek, Rehabilitation Centre and Centre for Language Studies, Radboud University, Nijmegen, the Netherlands
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Warrington and Halton Teaching Hospitals NHS Foundation Trust · Warrington Hospital
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Warrington Hospital, Warrington and Halton NHS Foundation Trust, Warrington, UK
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Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
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Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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University of Alabama at Birmingham · UAB Medicine
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UAB Epilepsy Centre, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
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Erasmus MC · Rijndam Revalidatiecentrum
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Department of Rehabilitation Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
Rijndam Rehabilitation, Rotterdam, the Netherlands
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Erasmus MC · Rijndam Revalidatiecentrum
Affiliation as printed
Department of Rehabilitation Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
Rijndam Rehabilitation, Rotterdam, the Netherlands
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Erasmus MC · Erasmus University Rotterdam
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Department of Neurology and Neurosurgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
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College of Allied Health Sciences, East Carolina University, Greenville, SC, USA
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