Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review–Based, Individual Participant Data Network Meta-Analysis

Brady, Marian C.; Ali, Myzoon; VandenBerg, Kathryn; Williams, Linda; Williams, Louise R.; Abo, Masahiro; Becker, Frank; Bowen, Audrey; Brandenburg, Caitlin; Breitenstein, Caterina; Bruehl, Stefanie; Copland, David A.; Cranfill, Tamara B.; Pietro-Bachmann, Marie di; Enderby, Pam; Fillingham, Joanne; Galli, Federica Lucia; Gandolfi, Marialuisa; Glize, Bertrand; Godecke, Erin; Hawkins, Neil; Hilari, Katerina; Hinckley, Jacqueline; Horton, Simon; Howard, David; Jaecks, Petra; Jefferies, Elizabeth; Jesus, Luís M. T.; Kambanaros, Maria; Kang, Eun Kyoung; Khedr, Eman M.; Kong, Anthony Pak‐Hin; Kukkonen, Tarja; Laganaro, Marina; Ralph, Matthew A. Lambon; Laska, Ann‐Charlotte; Leemann, Béatrice; Leff, Alexander; Lima, Roxele Ribeiro; Lorenz, Antje; MacWhinney, Brian; Marshall, Rebecca Shisler; Mattioli, Flavia; Maviş, İlknur; Meinzer, Marcus; Nilipour, Reza; Noé, Enrique; Paik, Nam–Jong; Palmer, Rebecca; Papathanasiou, Ilias; Patrício, Brígida; Martins, Isabel Pavão; Price, Cathy; Jakovac, Tatjana Prizl; Rochon, Elizabeth; Rose, Miranda; Rosso, Charlotte; Rubi-Fessen, Ilona; Ruiter, Marina B.; Snell, Claerwen; Stahl, Benjamin; Szaflarski, Jerzy P.; Thomas, Shirley; Sandt‐Koenderman, Mieke van de; Meulen, Ineke van der; Visch-Brink, Evy; Worrall, Linda; Wright, Heather Harris

doi:10.1161/strokeaha.121.035216

Cited by 54 publications

(20 citation statements)

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“…These results are generally concordant with the growing body of literature showing the benefits of high-dose and high-intensity SLT on communication outcomes [ 6 , 50 ]. Our work adds to this research by providing results for a large sample over a broad range of functional skill domains.…”

Section: Discussionsupporting

confidence: 87%

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Cordella¹,

Munsell²,

Godlove³

et al. 2022

J Med Internet Res

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Background Although the efficacy of high-dose speech-language therapy (SLT) for individuals with poststroke aphasia has been established in the literature, there is a gap in translating these research findings to clinical practice. Therefore, patients continue to receive suboptimal amounts of SLT, with negative consequences for their functional communication recovery. Recent research has identified self-managed digital health technology as one way to close the dosage gap by enabling high-intensity therapy unrestricted by clinician availability or other practical constraints. However, there is limited empirical evidence available to rehabilitation professionals to guide dose prescriptions for self-managed SLT despite their increasing use in the COVID-19 era and likely beyond. Objective This study aims to leverage real-world mobile health data to investigate the effects of varied dosage frequency on performance outcomes for individuals with poststroke speech, language, and cognitive deficits following a 10-week period of self-managed treatment via a commercially available digital health platform. Methods Anonymized data from 2249 poststroke survivors who used the Constant Therapy app between late 2016 and 2019 were analyzed. The data included therapy tasks spanning 13 different language and cognitive skill domains. For each patient, the weekly therapy dosage was calculated based on the median number of days per week of app use over the 10-week therapy period, binned into groups of 1, 2, 3, 4, or ≥5 days per week. Linear mixed-effects models were run to examine change in performance over time as a function of dosage group, with post hoc comparisons of slopes to evaluate the performance gain associated with each additional day of practice. Results Across all skill domains, linear mixed-effects model results showed that performance improvement was significantly greater for patients who practiced 2 (β=.001; t15,355=2.37; P=.02), 3 (β=.003; t9738=5.21; P<.001), 4 (β=.005; t9289=7.82; P<.001), or ≥5 (β=.005; t6343=8.14; P<.001) days per week compared with those who only practiced for 1 day per week. Post hoc comparisons confirmed an incremental dosage effect accumulating with each day of practice (ie, 1 day vs 2 days, 2 days vs 3 days, and 3 days vs 4 days), apart from 4 days versus ≥5 days of practice per week. The result of greater improvement for higher versus lower dosage frequency groups was true not only across all domains but also within a majority of individual subdomains. Conclusions The findings from this study demonstrated that increased dosage frequency is associated with greater therapy gains over a 10-week treatment period of self-managed digital therapy. The use of real-world data maximizes the ecological validity of study results and makes the findings more generalizable to clinical settings. This study represents an important step toward the development of optimal dose recommendations for self-managed SLT.

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Section: Discussionsupporting

confidence: 87%

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Cordella¹,

Munsell²,

Godlove³

et al. 2022

J Med Internet Res

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“…We created the international RELEASE IPD database of aphasia research to support several planned analyses, 15 , 19 , 20 systematically identifying and reviewing published and unpublished datasets with ⩾ 10 IPD on aphasia, language outcome, and time since stroke (reported in full elsewhere). 15 , 19 , 21 Briefly, several electronic databases, including MEDLINE and EMBASE, were searched (inception-September 2015 for eligible datasets). Anticipating lengthy data cleaning and analysis procedures, we also searched trial registrations for eligible trials completing beyond the electronic search date.…”

Section: Methodsmentioning

confidence: 99%

“…Anticipating lengthy data cleaning and analysis procedures, we also searched trial registrations for eligible trials completing beyond the electronic search date. 15 , 21 Non-English datasets were translated. Language data derived from stroke or screening measures were excluded.…”

Section: Methodsmentioning

confidence: 99%

“…Following a large IPD network meta-analysis, 15 our prespecified subgroup analysis aimed to explore language change from baseline to first post-intervention follow-up (measuring overall-language, auditory comprehension, and functional communication) for various levels of rehabilitation, intensity, dosage in aphasia subgroups, varying by participants’ age, sex, aphasia chronicity and severity at baseline.…”

Section: Aimsmentioning

confidence: 99%

“…Greatest auditory comprehension gains were associated with 9 + SLT-h weekly over 4-to-5 days. 15 Meta-analyses using IPD also support the exploration of differential treatment response across participants, 8 , 16 reducing the risk of ecological bias, facilitating the inclusion of previously unreported dropouts, outcome measurement, and follow-up data while increasing statistical power. 9 , 10 , 17 In a highly heterogeneous population such as people with aphasia, investigations of subgroups’ (based on age, aphasia severity, chronicity, or sex) treatment responsiveness might be explored with greater statistical power and adjustments for confounders than at trial level.…”

Section: Introductionmentioning

confidence: 99%

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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

Brady¹

2022

International Journal of Stroke

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Background Stroke rehabilitation interventions are routinely personalised to address individuals’ needs, goals and challenges based on evidence from aggregated randomised controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias. Aim We explored associations between speech and language therapy (SLT) interventions’, frequency (days/week), intensity (hours/week) and dosage (total SLT hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking pre-specified subgroup network meta-analyses of the RELEASE database. Methods MEDLINE, EMBASE and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ≥10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardised. A one-stage, random-effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomised by age (≤/>65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes median value), chronicity (≤/>3 months) and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (>50%), results were reported for completeness. Results 959 IPD (25 RCTs) were analysed. For working-age participants, greatest language gains from baseline occurred alongside moderate- to high-intensity SLT (functional communication 3-to-4 hours/week; overall-language and comprehension >9 hours/week); older participants’ greatest gains occurred alongside low-intensity SLT (≤2 hours/week) except for auditory comprehension (>9 hours/week). For both age-groups, SLT frequency and dosage associated with best language gains were similar. Participants ≤3 months post-onset demonstrated greatest overall-language gains for SLT at low-intensity/moderate-dosage (≤2 SLT-hours/week; 20-to-50 hours); for those >3 months post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-hours/week; ≥50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ≥4 SLT-days/week; mild-moderate participants’ greatest functional communication gains were associated with similar frequency (≥4 SLT-days/week), and greatest overall language gains with higher frequency SLT (≥6 days/weekly). Males’ greatest gains were associated with SLT of moderate (functional communication; 3-to-4 hours/weekly) or high intensity (overall language and auditory comprehension; (>9 hours/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (<2 SLT-hours/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-hours in total; auditory comprehension gains were generally observed when SLT >9 hours over ≥4 days/week. Conclusions We observed a treatment response in most subgroups’ overall-language, auditory comprehension and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical and cost-effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia-severity, and chronicity should be evaluated in future clinical RCTs. Protocol registration PROSPERO CRD42018110947

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Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia

Li,

Deng,

Zhuo

et al. 2024

JAMA Netw Open

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ImportanceMotor aphasia is common among patients with stroke. Acupuncture is recommended as an alternative therapy for poststroke aphasia, but its efficacy remains uncertain.ObjectiveTo investigate the effects of acupuncture on language function, neurological function, and quality of life in patients with poststroke motor aphasia.Design, Setting, and ParticipantsThis multicenter, sham-controlled, randomized clinical trial was conducted in 3 tertiary hospitals in China from October 21, 2019, to November 13, 2021. Adult patients with poststroke motor aphasia were enrolled. Data analysis was performed from February to April 2023.InterventionsEligible participants were randomly allocated (1:1) to manual acupuncture (MA) or sham acupuncture (SA) groups. Both groups underwent language training and conventional treatments.Main Outcomes and MeasuresThe primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and scores on the Chinese Functional Communication Profile (CFCP) at 6 weeks. Secondary outcomes included WAB subitems, Boston Diagnostic Aphasia Examination, National Institutes of Health Stroke Scale, Stroke-Specific Quality of Life Scale, Stroke and Aphasia Quality of Life Scale–39, and Health Scale of Traditional Chinese Medicine scores at 6 weeks and 6 months after onset. All statistical analyses were performed according to the intention-to-treat principle.ResultsAmong 252 randomized patients (198 men [78.6%]; mean [SD] age, 60.7 [7.5] years), 231 were included in the modified intention-to-treat analysis (115 in the MA group and 116 in the SA group). Compared with the SA group, the MA group had significant increases in AQ (difference, 7.99 points; 95% CI, 3.42-12.55 points; P = .001) and CFCP (difference, 23.51 points; 95% CI, 11.10-35.93 points; P &lt; .001) scores at week 6 and showed significant improvements in AQ (difference, 10.34; 95% CI, 5.75-14.93; P &lt; .001) and CFCP (difference, 27.43; 95% CI, 14.75-40.10; P &lt; .001) scores at the end of follow-up.Conclusions and RelevanceIn this randomized clinical trial, patients with poststroke motor aphasia who received 6 weeks of MA compared with those who received SA demonstrated statistically significant improvements in language function, quality of life, and neurological impairment from week 6 of treatment to the end of follow-up at 6 months after onset.Trial RegistrationChinese Clinical Trial Registry: ChiCTR1900026740

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Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review–Based, Individual Participant Data Network Meta-Analysis

Cited by 54 publications

References 49 publications

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

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

Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia

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