Chronic PWA should be offered therapy

5.4 People with chronic aphasia should be offered speech and language therapy to gain benefits in receptive and expressive language, and communication in everyday environments.


Reference: Brady et al., 2016: Cochrane review; Breitenstein et al., 2017: RCT; Fleming et al., 2021: RCT; Kristinsson et al., 2021: RCT; Palmer et al., 2019: RCT; Rose et al., 2022: RCT; Simmons-Mackie et al., 2016: Systematic review of 25 studies (11 group studies, 11 case studies, 2 qualitative studies and 1 SCED); The RELEASE collaborators, 2021:Meta-analysis of 174 studies (5928 IPD); The RELEASE collaborators, 2022a: Meta-analysis of 25 RCTs (959 IPD); The RELEASE collaborators, 2022b: Meta-analysis 25 RCTs (959 IPD); Zhang et al., 2017: Systematic review of 8 RCTs; 

NHMRC level of Evidence: I

Rationale: For people with chronic aphasia (more than 6 months post stroke onset), there is evidence to support the use of a number of behavioural treatments (Brady et al., 2016; The RELEASE collaborators, 2022a; 2022b). Treatments with high-level evidence of efficacy include constraint‐induced language therapy (Zhang et al., 2017), multimodality aphasia therapy (Rose et al., 2022), semantic and phonological lexical retrieval treatments (e.g., Kristinsson et al., 2021), auditory comprehension treatment (Fleming et al., 2021), self-managed computer-delivered therapy (Palmer et al., 2019), mixed linguistic and pragmatic therapy (Breitenstein et al., 2017), and training of conversation/communication partners (Simmons-Mackie et al., 2016).

 References:

1. Brady, M.C., Kelly, H., Godwin, J., Enderby, P., & Campbell, P. (2016). Speech and language therapy for aphasia following stroke. The Cochrane Database of Systematic Reviews, 6(6). DOI: 10.1002/14651858.cd000425.pub4
2. Breitenstein, C., Grewe, T., Flöel, A., Ziegler, W., Springer, L., Martus, P., Huger, W., Willmes, K., Ringelstein, E.G., Haeusler, K.G., Abel, S., Glindemann, R., Domahs, F., Regenbrecht, F., Schlenck, K., Thomas, M., Obrig, H., De Langen, E., Rocker, R., Wigbers, F., Rühmkorf, C., Hempen, I., List, J. & Baumgaertner, A. (2017). Intensive speech and language therapy in patients with chronic aphasia after stroke: A randomised, open-label, blinded-endpoint, controlled trial in a healthcare setting. Lancet, 389 (10078), 1528-1538. DOI: 10.1016/S0140-6736
3. Fleming, V., Brownsett, S., Krason, A., Maegli, M.A., Coley-Fisher, H., Ong, Y., Nardo, D., Leach, R., Howard, D., Robson, H., Warburton, E., Ashburner, J., Price, C. J., Crinion, J., & Leff, A.P. (2021). Efficacy of spoken word comprehension therapy in patients with chronic aphasia: A cross-over randomised controlled trial with structural imaging. Journal of Neurology, Neurosurgery and Psychiatry, 92(4), 418-424. DOI: 10.1136/jnnp-2020-324256
4. Kristinsson, S., Basilakos, A., Elm, J., Spell, L. A., Bonilha, L., Rorden, C., den Ouden, D. B., Cassarly, C., Sen, S., & Hillis, A. (2021). Individualized response to semantic versus phonological aphasia therapies in stroke. Brain Communications, 3(3). DOI: 10.1093/braincomms/fcab174
5. Palmer, R., Dimairo, M., Cooper, C., Enderby, P., Brady, M., Bowen, A., Latimer, N., Julious, S., Cross, E., Alshreef, A., Harrison, M., Bradley, E., Witts, H. & Chater, T. (2019). 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. The
6. Rose, M. L., Nickels, L., Copland, D., Togher, L., Godecke, E., Meinzer, M., Rai, T., Cadilhac, D. A., Kim, J., & Hurley, M. (2022). Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia. Journal of Neurology, Neurosurgery & Psychiatry, 93, 573-581. DOI: 10.1136/jnnp-2021-328422
7. Simmons-Mackie, N., Raymer, A., & Cherney, L.R. (2016). Communication partner training in aphasia: An updated systematic review. Archives of Physical Medicine and Rehabilitation, 97(2), 2202-2221. DOI: 10.1016/j.apmr.2016.03.023
8. The RELEASE Collaborators (2021). Predictors of Poststroke Aphasia Recovery: A Systematic Review-Informed Individual Participant Data Meta-Analysis. Stroke, 52(5):1778-1787. doi: 10.1161/STROKEAHA.120.031162.
9. The RELEASE collaborators. (2022a). Dosage, intensity and frequency of language therapy for aphasia: an individual participant data network meta-analysis. Stroke, 53(3). 956-967. DOI: 10.1161/STROKEAHA.121.035216
10. The RELEASE collaborators. (2022b). Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based individual participant data, network, subgroup meta-analysis. International Journal of Stroke, 17(10), 1067-1077. DOI: 10.1177/17474930221097477
11. Zhang, J., Yu, J., Bao, Y., Xie, Q., Xu, Y., Zhang, J., & Wang, P. (2017). Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials. PLoS One, 12(8), e0183349. DOI: 10.1371/journal.pone.0183349

Effectiveness of language therapy for people with chronic aphasia:

In 2012, Allen and colleagues completed a non-systematic review that looked at the effectiveness of interventions for chronic aphasia (initiated more than 6 months post stroke). 

The study included 21 RCTs which were rated for methodological quality using the PEDro scale. The majority of the studies were rated as "good" quality (PEDro score = 6-8/10).

FINDINGS: The review provided evidence for “computer-based treatments, constraint-induced therapy, intensive therapy, group language therapies, and training conversation/communication partners” (pp 523) with individuals with chronic aphasia. 

NOTES: Several of these results were supported by only one RCT and various therapies that have shown promising results in the acute setting have not been researched in the chronic stages (e.g. telerehabilitation).