Emma Patchick

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial

Objective To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact). Design Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment. Setting Twelve UK hospital and community stroke services. Participants 170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers. Interventions Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants’ needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors. Outcome measures Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants’ perceptions on the Communication Outcomes After Stroke scale (COAST); carers’ perceptions of participants from part of the Carer COAST; carers’ wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events. Results Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI –0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)). Conclusions Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160. Trial registration ISRCTN78617680

Investigating the efficacy of a virtual mirror box in treating phantom limb pain in a sample of chronic sufferers.

This paper describes a pilot clinical study to evaluate the efficacy of using immersive virtual reality (IVR) as a rehabilitative technology for phantom limb pain experienced by amputees. This work builds upon prior research which has used simple devices such as the mirror box (where the amputee sees a mirror image of their remaining anatomical limb in the phenomenal space of their amputated limb) to induce vivid sensations of movement originating from the muscles and joints of their phantom limb and to relieve pain. The IVR system transposes movements of amputees’ anatomical limbs into movements of a virtual limb which is presented in the phenomenal space of their phantom limb. The primary focus here is on a qualitative analysis of interview data with each participant throughout the study. We argue that the findings of this work make a case for proof of principle for this approach for phantom pain treatment.

The reliability of rating conversation as a measure of functional communication following stroke

Background: In assessing communication outcome in people following stroke, the emphasis has moved from impairment to its consequent effects on functional activity and participation in society. Alongside this has come an increasing focus on conversation. Conversation is a socially vital tool but its evaluation by speech and language therapists is not yet routine; detailed conversation analysis is time consuming and not easily quantified. In addition to the practical problems of assessing conversation, there are questions about its reliability as a basis for measurement. This study was funded from the UK Health Technology Assessment (HTA) programme (02/11/04) for the feasibility study of the Assessing the effectiveness of Communication Therapy in the North West (ACTNoW) study. The views expressed in the paper are those of the authors and not of the HTA. Grateful acknowledgement is made to all the study participants, speech and language therapists who were involved in recruitment, the expert SLT raters, and members of the Research User Group. Also to the ACTNoW Trial Management Group: A. Bowen (Principal Investigator), S. Davies, L. Davies, A. Hesketh, M. Lambon‐Ralph, A. F. Long, G. Pearl, K. Sage, P. Tyrrell, A. Vail, C. Watkins, M. Wilkinson, and A. Young. Particular thanks to Aneela Azfal, Gemma Paszek, Melanie Booth, and Jane Tyler (involvement in data acquisition) and to Svet Mihaylov (trial management). We are grateful to John Wiley and Sons, Ltd for permission to reproduce the Dysphasia/Aphasia Activity Scale from the Therapy Outcome Measures. Aims: Our context was the need for a measure of functional communication within a large‐scale randomised controlled trial of therapy for people with communication difficulty after stroke. The aim was to test the reliability of a clinically feasible procedure for collecting and rating a conversation sample. Methods and Procedures: Participants were 102 people who had had a stroke causing communication problems (aphasia and/or dysarthria) within the last 4–12 months; mean age 68 years; previously fluent English speakers; no pre‐existing progressive dementia or learning disability. Participants were videoed in conversation with an unfamiliar partner following a framework script, which was used as necessary to obtain a 10‐minute sample. Each participant was videoed twice within a 2‐week period. Videos were rated by unfamiliar specialist SLTs using the aphasia/dysarthria activity scale of the Therapy Outcome Measure (TOM). Measures of intra‐rater, inter‐rater, and conversation sample reliability were obtained. Outcomes and Results: Intra‐rater agreement was high; 93% of ratings were within a half point of each other on the TOM scale. The intra‐class correlation (ICC) for intra‐rater agreement was 0.92. Inter‐rater agreement was slightly lower with 77% of ratings within a half‐point on the 6‐point scale; ICC was 0.83. Conversation reliability was equally good; 78% of ratings were within a half‐point on the 6‐point scale; ICC was 0.82. With training in the use of the TOM rating scale, the expectation is for even higher levels of agreement. Conclusions: Our findings support the use of the TOM activity scale by an unfamiliar observer to rate a short conversation as part of outcome measurement. The use of independent expert SLTs to provide TOM activity level ratings on structured conversation samples with an unfamiliar partner reduced the variability known to affect judgements of conversation, and was shown to have promise as a clinically feasible, socially relevant and reliable measure.

VISTA-Rehab: A resource for stroke rehabilitation trials

Background Stroke rehabilitation is a complex intervention. Many factors influence the interaction between the patient and the elements of the intervention. Rehabilitation interventions are aimed at altering different domains of patient outcome including body functions, activity and participation. As a consequence, randomised clinical trials in this area are difficult to design. We developed an archive of stroke rehabilitation trials (VISTA-Rehab) to act as a resource to help trialists model and design future rehabilitation studies. Methods We developed specific eligibility criteria for the entry of stroke rehabilitation trials into the archive. We established a Steering Committee to oversee projects and publications and commenced the recruitment of rehabilitation trials into this resource. Results As of August 2009, VISTA-Rehab contains data from 23 stroke rehabilitation trials (>3400 patients). Demographic data, including age [median=73, interquartile range (63,79)], gender (male=53%) and initial dependency [median baseline Barthel index score=6, interquartile range (9,19)], are available for all patients. Outcome measures include the modified Rankin Scale, Barthel Index, Rivermead Motor Assessment, Fugl-Meyer Assessment, General Health Questionnaire and Nottingham Extended Activities of Daily Living Scale. Conclusion VISTA-Rehab expands the Virtual International Stroke Trials Archive to include rehabilitation trials. Anonymised data can be used to examine questions specific to stroke rehabilitation and to generate novel hypotheses.

PRECiS (Patient Reported Evaluation of Cognitive State): Psychometric evaluation of a new patient reported outcome measure of the impact of stroke

Objective: Determine the psychometric properties of PRECiS (Patient Reported Evaluation of Cognitive State): A new patient-centred, patient reported outcome measure for perceived impact of cognitive problems, developed through qualitative work, systematic review and service user consultation. Design: An observational study exploring acceptability, internal consistency, construct validity, inter-rater reliability and test-retest reliability, with opportunistic qualitative data on sensitivity to change. Setting: Home visits in the community. Participants: Stroke survivors with self-reported cognitive difficulties and informal carers. Measures: The 27 item PRECiS was self-completed with support, and proxy completed by informal carers. We collected descriptive cognitive screening test data, and measures of overall stroke impact, mood and activities of daily living to explore construct validity. Results: Data were collected from 159 (visit 1) and 66 (visit 2) stroke survivors and 86 informal carers. PRECiS showed good acceptability (no missing values or floor/ceiling effects, minimal skewness); high internal consistency (α = 0.94, indicative of potential redundancy); with moderate to strong construct correlations in the directions hypothesised (0.40 to 0.74). An intraclass correlation coefficient of 0.85 indicated good test-retest reliability. Where self-reported change had occurred from visit 1 to 2, PRECiS appeared sensitive. Using carers as proxy respondents is not supported by this analysis (inter-rater ICC = 0.43). Conclusions: PRECiS is a patient-centred, practical and reliable measure assessing perceived impact of cognitive problems from the unique perspective of stroke survivors.

Cognitive rehabilitation and recovery after stroke

As the previous chapters have described in detail, many of those fortunate to survive their stroke do so with detrimental alterations to their cognitive and psychological well-being. These impairments impact the affected individual’s ability to participate in, and benefit from, multidisciplinary stroke rehabilitation, to safely and independently carry out activities of everyday living, and to resume pre-morbid personal, social, and vocational roles [1–4]. Previously automatic and effortless tasks require exhausting levels of concentration and, despite the efforts invested, often end in perplexing and de-motivating failure. Uncertainty in one’s own abilities and reliance on others makes people with cognitive problems vulnerable to frustration, humiliation, worry, and feelings of hopelessness. These topics are covered elsewhere in this book. The current chapter focuses on cognitive rehabilitation by exploring the evidence base from the perspective of informing clinical service improvements and strives to root cognitive recovery firmly within a broader psychological context.

Authors' reply to Enderby, Meteyard, and Thornton

It is encouraging to see the Royal College of Speech and Language Therapists supporting randomised controlled trials (RCTs).1 2 Meteyard worries that RCTs will not cope with the complexity inherent after stroke.3 However, many RCTs have demonstrated the effectiveness of a range of complex interventions for heterogeneous populations (for example, stroke unit care, occupational therapy). As Enderby notes, the Cochrane review finds …