Rebecca Palmer

Computer Therapy Compared With Usual Care for People With Long-Standing Aphasia Poststroke A Pilot Randomized Controlled Trial

Background and Purpose— The purpose of this study was to test the feasibility of conducting a randomized controlled trial to study the effectiveness of self-managed computer treatment for people with long-standing aphasia after stroke. Method— In this pilot single-blinded, parallel-group, randomized controlled trial participants with aphasia were allocated to self-managed computer treatment with volunteer support or usual care (everyday language activity). The 5-month intervention period was followed by 3 months without intervention to investigate treatment maintenance. Results— Thirty-four participants were recruited. Seventeen participants were allocated to each group. Thirteen participants from the usual care group and 15 from the computer treatment group were followed up at 5 months. An average of 4 hours 43 minutes speech and language therapy time and 4 hours volunteer support time enabled an average of 25 hours of independent practice. The difference in percentage change in naming ability from baseline at 5 months between groups was 19.8% (95% CI, 4.4–35.2; P=0.014) in favor of the treatment group. Participants with more severe aphasia showed little benefit. Results demonstrate early indications of cost-effectiveness of self-managed computer therapy. Conclusion— This pilot trial indicates that self-managed computer therapy for aphasia is feasible and that it will be practical to recruit sufficient participants to conduct an appropriately powered clinical trial to investigate the effectiveness of self-managed computer therapy for people with long-standing aphasia. Clinical Trial Registration— www.controlled-trials.com. Unique identifier: ISRCTN91534629.

A Voice-Input Voice-Output Communication Aid for People With Severe Speech Impairment

A new form of augmentative and alternative communication (AAC) device for people with severe speech impairment-the voice-input voice-output communication aid (VIVOCA)-is described. The VIVOCA recognizes the disordered speech of the user and builds messages, which are converted into synthetic speech. System development was carried out employing user-centered design and development methods, which identified and refined key requirements for the device. A novel methodology for building small vocabulary, speaker-dependent automatic speech recognizers with reduced amounts of training data, was applied. Experiments showed that this method is successful in generating good recognition performance (mean accuracy 96%) on highly disordered speech, even when recognition perplexity is increased. The selected message-building technique traded off various factors including speed of message construction and range of available message outputs. The VIVOCA was evaluated in a field trial by individuals with moderate to severe dysarthria and confirmed that they can make use of the device to produce intelligible speech output from disordered speech input. The trial highlighted some issues which limit the performance and usability of the device when applied in real usage situations, with mean recognition accuracy of 67% in these circumstances. These limitations will be addressed in future work.

Methods of speech therapy treatment for stable dysarthria: A review

The objective of this review is to make treatment techniques published in the literature more easily accessible to clinicians in the field of stable dysarthria. This was achieved by performing a systematic review identifying and describing techniques for the treatment of stable dysarthria which have been the subject of published research. Electronic medical databases Medline, Cinahl and Amed were searched for literature published from 1966 to March 2006 that describe and or evaluate treatment techniques used for stable dysarthria. Of 46 papers found, 23 were included in the systematic review as they included the main concepts of stable dysarthria and treatment/therapy in the abstract. Published dysarthria treatment techniques reviewed are presented according to the parts of the speech system that they address. As the research studies published on stable dysarthria treatment use small numbers of participants and investigate very different treatment techniques, it is not possible to draw conclusions about the efficacy of different techniques. However, the review summarizes different treatment techniques for speech and language therapists to use with stable dysarthria and sign posts them to relevant literature.

Using computers to enable self-management of aphasia therapy exercises for word finding: the patient and carer perspective

BACKGROUND Speech and language therapy (SLT) for aphasia can be difficult to access in the later stages of stroke recovery, despite evidence of continued improvement with sufficient therapeutic intensity. Computerized aphasia therapy has been reported to be useful for independent language practice, providing new opportunities for continued rehabilitation. The success of this option depends on its acceptability to patients and carers. AIMS To investigate factors that affect the acceptability of independent home computerized aphasia therapy practice. METHODS & PROCEDURES An acceptability study of computerized therapy was carried out alongside a pilot randomized controlled trial of computer aphasia therapy versus usual care for people more than 6 months post-stroke. Following language assessment and computer exercise prescription by a speech and language therapist, participants practised three times a week for 5 months at home with monthly volunteer support. Semi-structured interviews were conducted with 14 participants who received the intervention and ten carers (n = 24). Questions from a topic guide were presented and answered using picture, gesture and written support. Interviews were audio recorded, transcribed verbatim and analysed thematically. Three research SLTs identified and cross-checked themes and subthemes emerging from the data. OUTCOMES & RESULTS The key themes that emerged were benefits and disadvantages of computerized aphasia therapy, need for help and support, and comparisons with face-to-face therapy. The independence, flexibility and repetition afforded by the computer was viewed as beneficial and the personalized exercises motivated participants to practise. Participants and carers perceived improvements in word-finding and confidence-talking. Computer practice could cause fatigue and interference with other commitments. Support from carers or volunteers for motivation and technical assistance was seen as important. Although some participants preferred face-to-face therapy, using a computer for independent language practice was perceived to be an acceptable alternative. CONCLUSIONS & IMPLICATIONS Independent computerized aphasia therapy is acceptable to stroke survivors. Acceptability can be maximized by tailoring exercises to personal interests of the individual, ensuring access to support and giving consideration to fatigue and life style when recommending practice schedules.

Addressing the needs of speakers with longstanding dysarthria: computerized and traditional therapy compared

BACKGROUND In clinical practice, it is common for speech and language therapists to discontinue dysarthria treatment when a plateau in spontaneous recovery is reached. However, there is some evidence from single-case research studies that people with chronic dysarthria can improve their speech with intervention several years after the onset of the disorder. If this is so, it can be argued that speech treatment should still be an option available to them. Motor learning principles suggest that in order to be effective, treatment needs to involve frequent, consistent practice with feedback. AIMS To compare the effects of both traditional treatment for clients with longstanding, stable dysarthria with computerized speech therapy, which allows independent practice with feedback. DEVELOPMENT OF THE COMPUTER PROGRAM: A new computer program was developed through a European Union-funded, quality of life and management of human resources programme. The program was designed for use with people with speech disorders and was based on motor learning principles. Speech recognition technology was exploited to provide feedback on practice attempts. METHODS & PROCEDURES Seven clients with longstanding, stable dysarthria completed a within-participant ABAC/ACAB case series design to compare 6-week blocks of weekly traditional treatment with 6-week blocks of computer-based treatment over a 6-month period. OUTCOMES & RESULTS The findings suggest that the participants improved their speech with treatment. The computerized therapy was as effective as traditional treatment. The participants spent more time (37%) with the computerized therapy than with traditional practice techniques. CONCLUSIONS The participants with longstanding dysarthria in this study made improvements to their speech with treatment using both traditional and computer-based techniques. Computers could provide a method of delivering an effective dysarthria treatment service without placing high demands on therapy resources.

COST-UTILITY OF SELF-MANAGED COMPUTER THERAPY FOR PEOPLE WITH APHASIA

OBJECTIVES The aim of this study was to examine the potential cost-effectiveness of self-managed computer therapy for people with long-standing aphasia post stroke and to estimate the value of further research. METHODS The incremental cost-effectiveness ratio of computer therapy in addition to usual stimulation compared with usual stimulation alone was considered in people with long-standing aphasia using data from the CACTUS trial. A model-based approach was taken. Where possible the input parameters required for the model were obtained from the CACTUS trial data, a United Kingdom-based pilot randomized controlled trial that recruited thirty-four people with aphasia and randomized them to computer treatment or usual care. Cost-effectiveness was described using an incremental cost-effectiveness ratio (ICER) together with cost-effectiveness acceptability curves. A value of information analysis was undertaken to inform future research priorities. RESULTS The intervention had an ICER of £3,058 compared with usual care. The likelihood of the intervention being cost-effective was 75.8 percent at a cost-effectiveness threshold of £20,000 per QALY gained. The expected value of perfect information was £37 million. CONCLUSIONS Our results suggest that computer therapy for people with long-standing aphasia is likely to represent a cost-effective use of resources. However, our analysis is exploratory given the small size of the trial it is based upon and therefore our results are uncertain. Further research would be of high value, particularly with respect to the quality of life gain achieved by people who respond well to therapy.

Initial evaluation of the Consent Support Tool: A structured procedure to facilitate the inclusion and engagement of people with aphasia in the informed consent process

Abstract This study evaluated the Consent Support Tool (CST), a procedure developed to identify the optimum format in which to present research information to people with different severities of aphasia, in order to support their understanding during the informed consent process. Participants were a convenience sample of 13 people with aphasia who had mixed comprehension ability. The CST was used to profile each participants language ability and identify an information format that should maximize her/his understanding. Next, participants were shown information presented in three formats: standard text and two ‘aphasia-friendly’ versions providing different levels of support. Participants’ understanding of the information was measured for each format. The format recommended by the CST was compared with the format observed to maximize understanding for each participant. The CST accurately predicted the optimum format for 11/13 participants and differentiated people who could understand fully with support from those who could not in 12/13 cases. All participants interviewed (10/10) found the adapted formats helpful and 9/10 preferred them to the standard version. These findings suggest that the CST could usefully support researchers to determine whether a person with aphasia is likely to be able to provide informed consent, and which information format will maximize that individuals understanding. The CST and different information formats are available as Supplementary Appendices to be found online at http://www.informahealthcare.com/doi/abs/10.3109/17549507.2013.795999.

Why do patients with stroke not receive the recommended amount of active therapy (ReAcT)? Study protocol for a multisite case study investigation

Introduction Increased frequency and intensity of inpatient therapy contributes to improved outcomes for stroke survivors. Differences exist in the amount of therapy provided internationally. In England, Wales and Northern Ireland it is recommended that a minimum of 45 min of each active therapy should be provided at least 5 days a week provided the therapy is appropriate and that the patient can tolerate this. Sentinel Stroke National Audit Programme (2014) data demonstrate this standard is not being achieved for most patients. No research been undertaken to explore how therapists in England manage their practice to meet time-specific therapy recommendations. The ReAcT study aims to develop an in-depth understanding of stroke therapy provision, including how the guideline of 45 min a day of each relevant therapy, is interpreted and implemented by therapists, and how it is experienced by stroke-survivors and their families. Methods and analysis A multisite ethnographic case study design in a minimum of six stroke units will include modified process mapping, observations of service organisation, therapy delivery and documentary analysis. Semistructured interviews with therapists and service managers (n=90), and with patients and informal carers (n=60 pairs) will be conducted. Data will be analysed using the Framework approach. Ethics and dissemination The study received a favourable ethical opinion via the National Research Ethics Service (reference number: 14/NW/0266). Participants will provide written informed consent or, where stroke-survivors lack capacity, a consultee declaration will be sought. ReAcT is designed to generate insights into the organisational, professional, social, practical and patient-related factors acting as facilitators or barriers to providing the recommended amount of therapy. Provisional recommendations will be debated in consensus meetings with stakeholders who have not participated in ReAcT case studies or interviews. Final recommendations will be disseminated to therapists, service managers, clinical guideline developers and policymakers and stroke-survivors and informal carers.

Exploring patient and public involvement in stroke research: a qualitative study

Abstract Purpose: To explore the experiences of patients and carers involved in patient and public involvement (PPI) activities for stroke research. Methods: Semi-structured interviews conducted with stroke survivors and carers (n = 11) were analysed using thematic analysis. Results: Four key themes emerged: impact of PPI on the individual and the research process, credibility and expertise, level of involvement and barriers and facilitators to PPI for stroke survivors and carers. The perceived benefits to the research process included: asking questions, keeping researchers grounded and directing the research agenda. All participants drew upon their experiential expertise in their PPI role, but some also drew upon their professional expertise to provide additional credibility. Stroke survivors and carers can be involved in PPI at different levels of involvement simultaneously and the majority of participants wanted to be more involved. Barriers to involvement included: location, transport and stroke survivors capacity to concentrate and comprehend complex information. Facilitators included: reimbursement for travel and time and professionals effort to facilitate involvement. Conclusions: PPI in stroke research benefits stroke survivors and carers and is perceived to benefit the research process. The barriers and facilitators should be considered by professionals intending to engage stroke survivors and carers collaboratively in research. Implications for Rehabilitation This study has implications for PPI in stroke rehabilitation research, which could also be extrapolated to stroke rehabilitation service development and evaluation. Professionals facilitating PPI need to invest in developing supportive relationships in order to maintain ongoing involvement. Professionals need to be aware of how the varied consequences of stroke might impede participation and strategies to facilitate involvement for all who wish to be involved. For each rehabilitation issue being considered professionals need to decide: (1) how representative of the specific rehabilitation population the PPI members need to be, (2) whether experience alone is sufficient or whether additional professional skills are required and (3) whether training is likely to assist involvement or potentially reduce the lay representation.

Preference-based health-related quality of life in the context of aphasia: a research synthesis

Background: Economic considerations are increasingly important in all areas of health care because of the need to determine the value of new and existing treatments. A key component of the current economic evaluation framework is the measurement of health outcomes in a manner that permits comparability across clinical areas—often referred to as “generic” outcome measurement—and incorporates societal preferences. Preference-based health-related quality of life (HRQoL) instruments are widely used to collect such data. Aims: To provide a research synthesis regarding the consideration and/or use of preference-based HRQoL instruments in the context of aphasia. A systematic search was conducted to identify aphasia-related publications that contained any of the leading preference-based instruments; in particular, the 15D, Assessment of Quality of Life (multiple variants), EQ-5D (three-level and five-level), Health Utilities Index (Mark 2 and Mark 3), Quality of Well-Being Scale Self-Administered, and/or SF-6D (SF-36 and SF-12 versions). In addition to providing an overview of how different measures have been used in aphasia research, a focus of the evaluation was to collate evidence for measurement properties and identify knowledge gaps, providing directions for further research. A secondary objective was to explore how preference-based measures have been discussed, broadly, in the aphasia literature. The latter objective originates from a desire to reflect the extent to which aphasia researchers have considered standard approaches to outcome measurement for the purposes of economic evaluation. Main Contribution: Eight publications (from six studies) were identified; the three-level EQ-5D was used on four occasions, and the 15D and an “accessible” version of the three-level EQ-5D were used once. The key finding is that there have been no psychometric evaluations of preference-based HRQoL instruments in the context of aphasia. One paper explicitly discussed the challenge of using standardised, generic preference-based instruments with individuals with aphasia; researchers devised an accessible version of the EQ-5D, based on pictures rather than text (this remains unvalidated and is not an official EQ-5D instrument). The absence of any supportive evidence regarding the performance of preference-based instruments in the context of aphasia hampers the ability to assess the cost-effectiveness of treatments and interventions within the current economic evaluation framework. Conclusions: There is a distinct lack of conceptual or empirical research regarding the appropriateness of current preference-based HRQoL instruments in the context of aphasia. Development and extensive validation of an accessible, generic preference-based HRQoL instrument appears to be an appropriate research direction.