Comparing higher and lower weekly treatment intensity for chronic aphasia: A systematic review and meta-analysis.

Optimizing intensity for aphasia treatment is a high priority research issue for people with aphasia, their families and clinicians, and could result in healthcare cost savings. An important aspect of intensity is the frequency of intervention, or how regularly treatment should be provided each week. While principles of neuroplasticity endorse massed practice, cognitive psychology has established superiority of distributed practice within normal learning. Neither concept has been conclusively tested in aphasia. There have been many literature reviews of intensity in aphasia intervention, but most have not investigated treatment intensity whilst also ensuring that therapy dose and treatment type are identical between study groups. Some have also combined studies across acute, subacute and chronic aphasia. We searched systematically for studies directly comparing higher and lower weekly treatment frequency in chronic aphasia. Eight studies were retrieved and rated for methodological quality. Meta-analysis was completed for group and single case experimental designs. Results showed that there are few studies investigating treatment frequency in chronic aphasia and their quality is low-moderate. Meta-analyses were inconclusive due to limited data, but there was no indication of either schedule being superior. Further research directly comparing treatment schedules is needed.

Constraint and multimodal approaches to therapy for chronic aphasia: A systematic review and meta-analysis.

Aphasia is a significant cause of disability and reduced quality of life. Two speech pathology treatment approaches appear efficacious: multimodal and constraint-induced aphasia therapies. In constraint-induced therapies, non-verbal actions (e.g., gesture, drawing) are believed to interfere with treatment and patients are therefore constrained to speech. In contrast, multimodal therapies employ non-verbal modalities to cue word retrieval. Given the clinical and theoretical implications, a comparison of these two divergent treatments was pursued. This systematic review investigated both approaches in chronic aphasia at the levels of impairment, participation and quality of life. After a systematic search, the level of evidence and methodological quality were rated. Meta-analysis was conducted on 14 single case experimental designs using Tau-U, while heterogeneity in the four group designs precluded meta-analysis. Results showed that high-quality research was limited; however, findings were broadly positive for both approaches with neither being judged as clearly superior. Most studies examined impairment-based outcomes without considering participation or quality of life. The application and definition of constraint varied significantly between studies. Both constraint and multimodal therapies are promising for chronic post-stroke aphasia, but there is a need for larger, more rigorously conducted studies. The interpretation of "constraint" also requires clearer reporting.

A systematic review of maintenance following intensive therapy programs in chronic post-stroke aphasia: importance of individual response analysis.

PURPOSE: Recent evidence supports the benefit of intensive aphasia intervention programs for people with chronic aphasia, yet it is unclear if all participants can expect positive outcomes and for how long therapeutic gains last. METHODS: We systematically searched for studies investigating intensive interventions in chronic aphasia. To explore individual response rates and maintenance of therapeutic gains we carried out meta-synthesis by calculating and analysing the Standard Error of Measurement and Minimal Detectable Change metrics of six common outcome measures. RESULTS: Forty-four studies comprising 24 experimental (13 group, 11 single-subject) and 20 non-experimental studies met our inclusion criteria (n = 670). Whereas most group studies reported statistically significant post-therapy improvement and maintenance, analysis of individual participant data (IPD, n = 393) from these studies revealed that only about a third of participants were classified as "immediate responders," of which more than a third had lost their initial immediate gains at follow-up. This pattern did not change when IPD from single-subject studies (n = 49) was added to the analysis. Thus, only 22% of all IPD receiving an intensive intervention improved significantly and maintained their therapy gains. CONCLUSIONS: Intensive aphasia therapy is effective when measured at the group-level, but many individuals do not respond significantly to the intervention, and even fewer individuals preserve their initial gains. Group study results do not allow prediction of an individual's response to the intervention. Future research should elucidate which factors mediate positive treatment response and maintenance for an individual.Implications for rehabilitationOnly a small proportion (about one fifth in this review) of intensive aphasia treatment program participants respond and maintain their therapy gains, a fact that is obscured by traditional p-value group analysis.A simple clinical decision-making method is presented for evaluating individual therapy gains and their maintenance.For some immediate treatment responders (about one third in this review), gains from intensive therapy programs are unlikely to be maintained in the long-term without additional, ongoing practice.Clinicians should consider the possibility of individual clients losing some of their therapy gains and take proactive steps to support long-term maintenance.