Poststroke speech therapy ‘should be reorganized’

By Eleanor McDermid

Results of the randomized ACT NoW trial show no benefit of "enhanced" over "everyday" communication therapy for patients with dysarthria resulting from stroke.

Overall, communicative ability in the 170 patients in ACT NoW (Assessing Communication Therapy in the North West) improved over the study period, from a baseline average of 2.4 points on the activity level scale of the Therapy Outcome Measure to a 6-month average of 3.2 points.

This represented a clinically meaningful improvement; however, the 0.25-point difference in improvement between patients randomly assigned to enhanced or to everyday communication therapy was not statistically significant.

"When the full ACT NoW evidence is considered within the context of other recent trials and reviews, it is clear that early communication services should be reorganised," the researchers write in the BMJ.

But they stress: "There is no suggestion that speech and language therapists should be removed from the early stage of the stroke pathway."

There is a "firm consensus" that communication therapy is beneficial after stroke, say Audrey Bowen (University of Manchester, UK) and colleagues. Thus, the ACT NoW findings simply indicate that one-to-one individualized therapy may be unnecessary, at least in the early stages after stroke.

The enhanced intervention in ACT NoW consisted of flexible, tailored speech and language therapy delivered by a therapist. Patients received an average of 18 hours of therapy over 13 weeks, starting an average of 12 days after stroke. The everyday communication intervention comprised an equivalent amount of contact from nontherapists employed to visit the patients; they usually talked to the patients or, less frequently, engaged in activities such as games, jigsaws, or watching television.

"The effectiveness of later provision by speech and language therapists remains an important clinical question warranting a clinical trial," notes the team.

Editorialists Anthony Rudd and Charles Wolfe (King's College London, UK) welcome the findings, saying that "as with other treatment interventions, it is essential that rehabilitation is subjected to rigorous scrutiny."

They say: "More focus on the early phase mechanisms that underpin the speech deficit may be needed before further pragmatic trials are undertaken. Although the results do highlight that scarce professional speech and language therapy resources may be inappropriately allocated at present, they do not spell the end of such therapy in the acute phase of stroke rehabilitation."

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