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in Communication Disorders
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Aphasia
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External Scientific Evidence

  

Evidence-Based Practice Guidelines

Scottish Intercollegiate Guidelines Network
 
Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications, and Discharge Planning
Scottish Intercollegiate Guidelines Network. (2010).
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN), SIGN Publication No. 108, 118 pages
.
Added: May 2012
 
Description

This guideline provides recommendations for the management, rehabilitation, and prevention of complications for individuals up to one year post-stroke. The intended audiences for this review include health care professionals. Recommendations are graded A, B, C, D, or "Good Practice Point" based on the strength of supporting evidence using the following criteria:

  • Grade A: Recommendations  based on evidence from systematic reviews and meta-analyses of randomized controlled trials that are directly relevant to the population.
  • Grade B: Recommendations based on high quality case control or cohort studies or high quality systematic reviews of those studies that are directly applicable to the population, or recommendations extrapolated from Grade A evidence.
  • Grade C: Recommendations based on well conducted case control or cohort studies or recommendations extrapolated from Grade B evidence.
  • Grade D: Recommendations based on evidence from non-analytic studies or expert opinion or recommendations extrapolated from Grade C evidence.
  • Good Practice Points: Recommendations based on the clinical experience of the guideline development group
Recommendations
  • For individuals with aphasia who are sufficiently well and motivated, a minimum of two hours per week of treatment is recommended (Grade B Evidence).
  • Where appropriate, length of aphasia treatment may require a minimum of six months (Good Practice Point)
 
 
 
Royal College of Physicians; Stroke Association; Broehringer Ingelheim; Merck Sharp & Dohme; Sanofi-Sythelapo & Bristol-Myers Squibb
 
National Clinical Guidelines for Stroke
Intercollegiate Stroke Working Party (2008).
London (United Kingdom): Royal College of Physicians, 3rd Edition, 187 pages
Added: May 2012 
 
Description
This guideline provides recommendations for the management of stroke across all populations. The audiences intended for this guideline include clinical staff, managers, commissioners involved in the purchasing of services, patients with stroke and their caregivers. Of particular interest to speech-language pathologists is a section on the management of swallowing and communication disorders. Specific recommendations were made based on the nature and strength of the evidence using a formal consensus approach by the guideline working group
 
Recommendations
Early intensive treatment consisting of two to eight hours per week should be considered for individuals with aphasia
 
 
 
 
Catalan Agency for Health Technology Assessment and Research
 
Stroke: Clinical Practice Guideline (2nd edition)
Catalan Agency for Health Technology Assessment and Research. (2007).
Barcelona (Spain): Catalan Agency for Health Technology Assessment and Research, 112 pages
Added: May 2012 
 
Description

This guideline provides recommendations for the assessment, management, and rehabilitation of acute stroke in adults. The target audiences for this guideline include professionals, managers, and planners involved in the care of adults with acute stroke. Of particular interest to speech-language pathologists is the section on assessment and intervention for aphasia, dysarthria, cognitive disorders and dysphagia. Recommendations are graded A, B, C, D, or "Point of Good Practice" based on the strength of supporting evidence below:  

  • Grade A: Recommendations based on evidence from systematic reviews and meta-analyses of randomized controlled trials that are directly relevant to the population.
  • Grade B: Recommendations based on high quality case control or cohort studies or high quality systematic reviews of those studies that are directly applicable to the population, or recommendations extrapolated from Grade A evidence.
  • Grade C: Recommendations based on well conducted case control or cohort studies or recommendations extrapolated from Grade B evidence.
  • Grade D: Recommendations based on evidence from non-analytic studies or expert opinion or recommendations extrapolated from Grade C evidence.
  • Points of Good Practice: Recommendations based on the clinical experience of the guideline development group
Recommendations
  • Individuals with stroke-induced aphasia may benefit from intensive speech therapy in a short period of time (Grade B Evidence).
  • Evidence suggests that individuals with stroke-induced aphasia receive SLP treatment between two to eight hours a week (Grade B Evidence)
 
 
 
Department of Veterans Affairs; Department of Defense; American Heart Association / American Stroke Association
 
VA/DOD Clinical Practice Guideline for the Management of Stroke Rehabilitation
Management of Stroke Rehabilitation Working Group. (2010).
Veterans Health Administration, Department of Defense, 150 pages
Added: May 2012 
 
Description

This guideline provides recommendations for the assessment and management of adult patients (18 years or older) with post-stroke functional disability receiving services in the Veteran's Health Administration (VHA) or Department of Defense (DoD) healthcare system. The target audience of this guideline is VHA and DoD health care professionals providing treatment in primary care, specialty care, long-term care or community settings. Of particular interest to speech-language pathologists is a section on the management of communication impairments (aphasia, dysarthria, apraxia), cognitive impairments and swallowing. Recommendations are graded A, B, C, D or I based on the following criteria:  

  • Grade A: A strong recommendation that clinicians provide the intervention to eligible patients based on good evidence that the intervention improves important health outcomes and benefits substantially outweigh harms.
  • Grade B: A recommendation that clinicians provide the intervention to eligible patients based on at least fair evidence that the intervention improves health outcomes and benefits outweigh harms.
  • Grade C: No recommendation for or against the provision of the intervention. At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
  • Grade D: Recommendation against providing the intervention based on at least fair evidence that the intervention is ineffective or that harms outweigh benefits.
  • Grade I: Information insufficient to recommend for or against providing the intervention. Evidence that intervention is effective is either lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.  
Recommendations
Aphasia treatment should be provided at a higher intensity rather than a lower intensity (Grade B Evidence). 
 
 
 
 
 
Evidence-Based Systematic Reviews
Therapeutic Interventions for Aphasia Initiated More Than Six Months Post Stroke: A Review of the Evidence
Allen, L., Mehta, S., et al. (2012).
Topics in Stroke Rehabilitation, 19(6), 523-535.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: May 2013

Description
This is a review of randomized controlled trials examining the efficacy of aphasia treatments provided to individuals with 6 months post onset of stroke-induced aphasia.

Conclusions

  • Evidence was found in support of a number of treatments for individuals with chronic aphasia. These included:
    • computer-based aphasia treatments

    • constraint-induced language aphasia therapy

    • delivery of intensive aphasia therapy

    • conversation partner training

  • Given the heterogeneity of patients included and wide range of interventions included, further research is warranted.

» See full summary and quality ratings



Speech and Language Therapy for Aphasia Following Stroke
Brady, M. C., Kelly, H., et al. (2012).
Cochrane Database of Systematic Reviews, 5, CD000425.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: October 2012

Description
This is an update of an original systematic review by Greener et al. (1999) and subsequent review by Kelly et al. (2010) investigating the effects of speech language therapy intervention in adults with stroke-induced aphasia.

Conclusions

  • Six trials investigated intensive versus conventional speech and language treatment. Preliminary results from one trial favored intensive treatment over conventional treatment to improve functional communication and writing skills.

  • No evidence of difference was found in receptive language skills.

» See full summary and quality ratings


 

Evidence-Based Review of Stroke Rehabilitation
Teasell, R. W., Foley, N. C., et al. (2011).
Retrieved from http://www.ebrsr.com
.
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: October 2012 
 
Description

This is an update of the Teasell et al. (2009) evidence-based review investigating the effectiveness of pharmacological and non-pharmacological interventions for stroke rehabilitation. Of particular interest to speech-language pathologists are the modules specific to aphasia, dysphagia, perceptual disorders and cognitive disorders. The levels of evidence used to summarize the review findings are based on the United States Agency for Health Care Policy and Research (AHCPR) criteria:  

  • Level 1a: Strong evidence supported by a meta-analysis or two or more randomized controlled trials (RCTs) with at least “fair” quality.
  • Level 1b: Moderate evidence supported by at least one RCT of “fair” quality.
  • Level 2: Limited evidence supported by at least one controlled trial with a minumum of 10 participants in each arm of the study.  
  • Level 3: Findings supported by expert consensus opinion in the absence of evidence.
  • Level 4: Conflicting evidence based on disagreement between the findings of at least two RCTs. Where there are more than four RCTs, conclusions are based on the results of the majority of studies, unless conflicting results are reported in a higher quality study.  
Conclusions
  • Based on the results of the two meta-analyses, the authors conclude there is strong (Level 1a) evidence in support of intensive speech and language treatment (SLT) over less intensive, conventional SLT. Intensive treatement produced more significant benefits than conventional SLT (Module 14; p. 18). 
  • The authors conclude that "language therapy is efficacious in treating aphasia when provided intensely for the first 3 months; less intensive therapy given over a longer period of time does not provide a statistically significant benefit, although clinical benefits can be achieved" (Module 14; p. 18)
  • The authors also indicate that "intensive language therapy may be associated with improved language function for individuals with global aphasia" (Module 14; p. 70). 
 


 

Intensity of Aphasia Therapy, Impact on Recovery
Bhogal, S. K., Teasell, R., et al. (2003).
Stroke, 34(4), 987-993
.
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: May 2012 
 
Description
This is a review of clinical trials investigating the relationship between intensity of aphasia therapy and aphasia recovery post stroke
 
Conclusions
The authors conclude that intense therapy over a short amount of time can improve outcomes of speech and language therapy for individuals with stroke-induced aphasia. Specifically, the authors indicated that studies that demonstrated a significant treatment effect "provided an average of 8.8 hours of therapy per week for 11.2 weeks compared with the 4 negative studies that only provided two 1-hour sessions per week for 22.9 weeks" (p. 991)
 
 
 
  
 
Rehabilitation of Aphasia: More Is Better
Bhogal, S. K., Teasell, R. W., et al. (2003).
Topics in Stroke Rehabilitation, 10(2), 66-76
.
Added: May 2012 
 
Description
This is a review of studies investigating the effects of aphasia speech and language therapy on individuals post-stroke
 
Conclusions
  • Strong evidence supports intensive aphasia treatment over a short period of time to improve speech and language outcomes.
  • The authors found that studies demonstrating a significant treatment effect "provided an average of 8.8 hours of therapy per week for 11.2 weeks compared with the 4 negative studies that only provided two 1-hour sessions per week for 22.9 weeks" (p. 991)
 
 
 
Updated Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals with Stroke-Induced Aphasia
Cherney, L. R., Patterson, J. P., et al. (2010).
Rockville (MD): American Speech-Language-Hearing Association, 36 pages
.
 
This review meets the criteria for a high-quality evidence-based systematic review.
 
Added: May 2012 
 
Description
This is an update of the Cherney et al. 2008 review of peer-reviewed studies investigating the effects of constraint-induced language therapy (CILT) and intensity of treatment for individuals with stroke-induced aphasia
 
Conclusions
  • In the original review, modest treatment effects were found supporting more intensive language treatment for individuals with stroke-induced aphasia. However given the small number of studies, range of methodological quality and range of participant characteristics and outcomes, these results were considered preliminary.
  • The results from the updated review reported mixed findings on measures of language impairment. "These findings differ from the original review in which the majority of studies found increased treatment intensity to be associated with positive changes in outcome measures of language impairment" (pp. 3-4)
 
 
 
Intensity of Aphasia Therapy: Evidence and Efficacy
Cherney, L. R., Patterson, J. P., et al. (2011).
Current Neurology and Neuroscience Reports, 11(6), 560-9
.
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: May 2012 
 
Description
This is an update of a systematic review (Cherney et al., 2008) investigating the impact of treatment intensity on language and communication outcomes for individuals with stroke-induced aphasia
 
Conclusions
  • The updated review identified three new studies pertaining to intensity of aphasia treatment.
  • In the previous review, results from one study favored more intensive treatment for measures of language impairment in individuals with acute aphasia. An additional study from this review reported equivocal results. However, the authors indicated that many of the participants did not receive the intensive amount of treatment suggesting that intensive treatment may not be feasible in the early stage of recovery.
  • No studies examining activity/participation communication outcomes in individuals with acute aphasia were found.
  • In the previous review, results from five studies favored more intensive treatment over less intensive treatment for improving language impairment outcomes for individuals with chronic aphasia. In the current review, three additional studies provided mixed results.
  • Findings remain mixed for communication outcomes at the level of activity/participation for individuals with chronic aphasia.
  • Further methodologically sound research is warranted
 
 

Clinical Expertise/Expert Opinion

 
Consensus Guidelines  
No consensus guidelines were found. 
 
 
 
 

Client/Patient/Caregiver Perspectives

 
Constraint Induced Language Therapy in Early Aphasia Rehabilitation
Kirmess, M., & Maher, L. M. (2010).
Aphasiology, 24(6-8), 725-736
.
Added: May 2012
 
Description
This is a pre/post study of three individuals with acute stroke-induced aphasia examining the impact of constraint-induced language treatment on expressive language outcomes. Patient satisfaction outcomes were also reported
 
Conclusions
Mixed findings were reported regarding intensity of constraint-induced language therapy; two participants preferred a less intensive intervention and one preferred a more intensive treatment
 
 
 
 
Family Members' Report on Speech-Language Pathology and Community Services for Persons with Aphasia in Hong Kong
Kong, A. P. (2011).
Disability and Rehabilitation, 33(25-26), 2633-45
Added: May 2012
 
Description
This is a qualitative study of 37 family members of individuals with aphasia. This study examines treatments provided by speech-language pathology (SLP) services and the perspectives of SLP treatment provided from the family member's point of view regarding services delivered in inpatient, outpatient and community-based settings
 
Conclusions
  • Satisfaction of family members regarding the duration and frequency of SLP services were 27% and 24% respectively.
  • The majority of participants were dissatisfied with SLP services citing the need for more frequent SLP treatment sessions provided in hospital-based inpatient settings (53%) and more intensive individual or group SLP treatment provided in hospital-based SLP outpatient settings (48%).
 

 
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