speech and language therapy with stroke patients

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Speech and language therapy
Clinical information
Stroke – overview

Stroke - overview

Ischaemic stroke: blockage cutting off the blood supply to the brain
Haemorrhagic stroke: caused by a bleeding in or around the brain

Page content

What is a stroke, role of speech and language therapy for stroke, related topic areas, key organisations.

If you’re a speech and language therapist, please sign up or log in to access the full version of this content.

A stroke occurs when the blood flow to part of the brain is cut off.

A transient ischaemic attack or TIA, sometimes referred to as a mini-stroke, is defined as stroke symptoms and signs that resolve within 24 hours.

Effects of stroke

A stroke can affect many different body functions, depending on the part of the brain that is involved, including:

Problems with swallowing – Dysphagia
Problems with communication, including Aphasia , dysarthria and apraxia. See Acquired motor speech disorders

The SLT has a key role in:

Initial assessment of swallowing and communication difficulties following acute stroke
Training of other healthcare professionals to carry out screening
Long-term rehabilitation of stroke patients as part of the core multidisciplinary stroke rehabilitation team
Coaching others, including carers and other professionals, to facilitate communication
Supporting the medical team to assess capacity, in cases in which it is difficult to obtain consent from a person.

For further information read our stroke fact sheet (PDF)

For more videos visit the RCSLT YouTube channel .

Acquired motor speech disorders
Augmentative and alternative communication (AAC)
Brain injury
Mental capacity and supported decision making
Mental health (adults)
Motor disorders
Respiratory care (adults)
Visual impairment
Chest Heart & Stroke Scotland
Different Strokes: Support for younger stroke survivors

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Back to Contents page
What’s new in the 2023 edition
1.0 Introduction
1.2 Context and use of this guideline
1.3 Models underpinning guideline development
1.4 Methodology of guideline development
1.5 Funding and conflicts of interest
1.6 Treatments not mentioned in this guideline
1.7 Participation in clinical research
1.8 Licensing and approval of medication
1.9 Contributors
1.10 Notes on the text
2.0 Introduction
2.1 Public awareness of stroke
2.2 Definitions of specialist stroke services
2.3 Transfer to acute stroke services
2.4 Organisation of inpatient stroke services
2.5 Resources – inpatient stroke services
2.6 Location of service delivery
2.7 Transfers of care – general principles
2.8 Transfers of care from hospital to home – community stroke rehabilitation
2.9 Remotely delivered therapy and telerehabilitation
2.10 Measuring rehabilitation outcomes
2.11 Psychological care – organisation and delivery
2.12 Vocational rehabilitation
2.13 Follow-up review and longer term support
2.14 Stroke services for younger adults
2.15 End-of-life (palliative) care
2.16 Carers
2.17 People with stroke in care homes
2.18 Service governance and quality improvement
3.0 Introduction
3.1 Pre-hospital care
3.2 Management of TIA and minor stroke – assessment and diagnosis
3.3 Management of TIA and minor stroke – treatment and vascular prevention
3.4 Diagnosis and treatment of acute stroke – imaging
3.5 Management of ischaemic stroke
3.6 Management of intracerebral haemorrhage
3.7 Management of subarachnoid haemorrhage
3.8 Cervical artery dissection
3.9 Cerebral venous thrombosis
3.10 Acute stroke care
3.11 Positioning
3.12 Early mobilisation
3.13 Deep vein thrombosis and pulmonary embolism
4.0 Introduction
4.1 Rehabilitation potential
4.2 Rehabilitation approach – intensity of therapy (motor recovery and function)
4.3 Rehabilitation approach – goal setting
4.4 Self-management
4.5 Remotely delivered therapy and telerehabilitation
4.6 Self-directed therapy
4.7 Introduction
4.8 Independence in daily living
4.9 Hydration and nutrition
4.10 Mouth care
4.11 Continence
4.12 Extended activities of daily living
4.14 Driving
4.15 Return to work
4.16 Introduction
4.17 Motor impairment
4.18 Arm function
4.19 Ataxia
4.20 Balance
4.21 Falls and fear of falling
4.22 Walking
4.23.1 Neuropathic pain (central post-stroke pain)
4.23.2 Musculoskeletal pain
4.23.3 Shoulder subluxation and pain
4.24 Spasticity and contractures
4.25 Fatigue
4.26 Swallowing
4.27 Introduction
4.28 Psychological effects of stroke – general
4.29 Cognitive screening
4.30 Cognitive assessment
4.31 Apraxia
4.32 Attention and concentration
4.33 Memory
4.34 Executive function
4.35 Mental capacity
4.36 Perception
4.37 Neglect
4.38 Mood and well-being
4.39 Anxiety, depression and psychological distress
4.40 Apathy
4.41 Emotionalism

4.42 Introduction

4.43 aphasia, 4.44 dysarthria, 4.45 apraxia of speech.

4.46 Introduction
4.47 Sensation
4.48 Vision
5.0 Introduction
5.1 A comprehensive and personalised approach
5.2 Identifying risk factors
5.3 Carotid artery stenosis
5.4 Blood pressure
5.5 Lipid modification
5.6 Antiplatelet treatment
5.7 Anticoagulation
5.8 Other risk factors
5.9 Paroxysmal atrial fibrillation
5.10 Patent foramen ovale
5.11 Other cardioembolism
5.12 Vertebral artery disease
5.13 Intracranial artery stenosis
5.14 Oral contraception and hormone replacement therapy
5.14.1 Oral contraception
5.14.2 Hormone replacement therapy
5.15 Obstructive sleep apnoea
5.16 Antiphospholipid syndrome
5.17 Insulin resistance
5.18 Fabry disease
5.19 Cerebral Amyloid Angiopathy
5.20 CADASIL
5.21 Cerebral microbleeds
5.22 Lifestyle measures
5.23 Physical activity
5.24 Smoking cessation
5.25 Nutrition (secondary prevention)
5.26 Life after stroke
5.27 Further rehabilitation
5.28 Social integration and participation
6.0 Introduction
6.1 Overall structure of stroke services
6.2 Acute stroke services
6.3 Secondary prevention services
6.4 Stroke rehabilitation services
6.5 Long-term support services
Acronyms and abbreviations
Bibliography
Contributors
Evidence tables & additional evidence assessed
Previous editions of the guideline

Rehabilitation and recovery – communication and language

This section covers the range of speech and language problems that can occur after stroke with recommendations to help the person with stroke to communicate and increase social par ... Show more

This section covers the range of speech and language problems that can occur after stroke with recommendations to help the person with stroke to communicate and increase social participation. Swallowing impairment (dysphagia) is covered in Section 4.26 Swallowing . [2023]

Aphasia refers to an impairment of language function affecting all aspects of communication including speaking, understanding, reading (separately called alexia) and writing (agrap ... Show more

Aphasia refers to an impairment of language function affecting all aspects of communication including speaking, understanding, reading (separately called alexia) and writing (agraphia). Aphasia affects about a third of people with stroke, and can have a significant impact on the lives of individuals and their family/carers. Aphasia has wide-ranging effects on mood, self-image, well-being, relationships, employment, leisure and social opportunities. Problems with communication can also occur following damage to the non-dominant hemisphere. [2023]

Delivery of speech and language interventions can be described under two main approaches: interventions delivered by trained professionals (e.g. speech and language therapists), which are currently the majority and address many aspects of language use, and digital therapies delivered on computers, mobile devices or as apps, which tend to target a specific aspect of language function e.g. the ability to retrieve and produce specific spoken words. Some studies have investigated a blend of the two approaches and use mainstream and specialist software to augment therapist-delivered speech and language therapy. In order to evaluate complex interventions such as speech and language therapy (SLT) a broad range of studies are required (Skivington et al, 2021). [2023]

People should be assessed early after stroke for communication difficulties by a speech and language therapist to diagnose the problem, devise and implement a treatment programme and explain the nature and implications to the person, their family/carers and the multidisciplinary team. [2023]

People with aphasia after stroke should be given the opportunity to improve their language and communication abilities as frequently and for as long as they continue to make meaningful gains, under supervision from a speech and language therapist. [2023]

People with aphasia after stroke should be offered access to appropriate practice-based digital therapies. Adherence to and engagement with these digital therapies will likely be improved if supported by a carer or healthcare professional. Telerehabilitation programmes should:

be personalised to the individual’s goals and preferences;
be used when it is considered to be a beneficial option to promote recovery and should not be used as an alternative to in-person rehabilitation;
be monitored and adapted by the therapist according to progress towards goals;
be supplemented with face-to-face reviews and include the facility for contact with the therapist as required. [2023]

People with communication difficulties after stroke should:

be assessed and offered access to a range of communication aids, prescribed according to the person’s needs, goals, and preferences;
be assessed for their ability to use assistive technology and have programmes and equipment adjusted accordingly;
be trained and supported in the use of the appropriate technology. [2023]

People with communication difficulties after stroke should be offered access to social and participatory activities such as conversation partners, peer support groups, and return to work programmes as appropriate. [2023]

People with aphasia after stroke whose first language is not English should be assessed and provided with information about aphasia and offered therapy and communication practice in their preferred language. Referral to appropriate services such as interpreters should be made promptly to facilitate early assessment and treatment. [2023]

Intensive speech and language therapy such as comprehensive aphasia programmes may be considered from 3 months after stroke for those who can tolerate high-intensity therapy. [2023]

People with aphasia after stroke should be monitored and assessed for depression and other mood disorders using validated tools. Accessible information should be provided and psychological interventions tailored to the person’s needs. [2023]

The carers and family of a person with communication difficulties after stroke, and health and social care staff, should receive information and training from a speech and language therapist to improve their communication skills and enable them to optimise engagement in the person’s rehabilitation, and promote autonomy and social participation. [2023]

People with persistent communication difficulties after stroke, that limit their social activities, should be offered information about local or national groups for people with aphasia and referred as appropriate. [2023]

A high quality meta-analysis carried out by the RELEASE Collaborators (2022b) re-examined data from 25 published trials involving 959 people with aphasia across 10 different languages. This meta-analysis demonstrated a clear dose effect (total hours of therapy); that is, people with aphasia who received more hours of therapy (more than 20 to 50 hours) made large and clinically meaningful gains in language abilities and function, compared with those who received fewer hours. No functional communication gains were observed for people with aphasia receiving less than 5 hours of therapy nor comprehension gains for those receiving less than 20 hours. There was a weaker effect of frequency (number of days per week that therapy was delivered) with 3-5 days being best. The data on intensity (hours of therapy per week) were less clear (Dignam et al, 2015; RELEASE Collaborators, 2022a). [2023]

The majority of evidence derives from people with aphasia in the chronic phase (more than 6 months after stroke but often much longer than this). There is no evidence to support a set time limit after stroke when therapy should be stopped. People with aphasia should be offered therapy for as long as they continue to make meaningful gains in their language and communication abilities (RELEASE Collaborators, 2021). [2023]

The greatest overall gains in language outcomes for people with aphasia after stroke are seen when therapy starts in the acute/subacute stage, within 1 month of stroke (RELEASE Collaborators, 2021). There is less evidence regarding the intensity and dose for people with aphasia when treatment starts within one month of stroke. A high quality RCT of people with acute stroke showed no difference between 10 hours (control group) and 23 hours (active group) of speech and language therapy delivered over a month (Godecke et al, 2021). [2023]

For people with aphasia in the chronic phase (more than 3 months after stroke) the greatest gains were associated with moderate-intensity/high-dose therapy (3-4 hours/week; more than 50 hours of treatment in total; (RELEASE Collaborators, 2022b)). One way of delivering higher doses of therapy is through comprehensive aphasia programmes, with positive results seen in one non-randomised trial (Hoover et al, 2017) and one observational study (Leff et al, 2021). However, not all people with aphasia can manage the high-intensity treatment mandated by these programmes. These studies suffer from selection bias and their results cannot be generalised to all people with aphasia, and more high quality research is needed. [2023]

There has been a lot of interest in digital therapies for people with aphasia, with several RCTs demonstrating large gains in naming in particular (Palmer et al, 2019; Braley et al, 2021). It should be noted that the majority of digital therapies are not designed to replicate the interventions delivered by a speech and language therapist – rather, they automate the repetitive and often impairment-based aspects of therapy. As such, their effects are often only seen on the aspects of language, or items, that the person with aphasia practices. There is good evidence that both clinician and self-administered digital therapies can be effective (Lavoie et al, 2017), but those with more support from carers or therapists tend to engage more and make larger language gains (Harrison et al, 2020). [2023]

Stroke services should consider all the ways that the dose of speech and language therapy can be increased to the levels recommended here, as they are considerably higher than currently delivered. Holistic aspects of rehabilitation such as peer support, social and singing groups may have communication benefits as they provide opportunity for social communication practice. Groups or programmes (such as return to work) should be facilitated and adapted to ensure accessibility for those with aphasia. Aphasia-specific participation activities, such as with communication partners from the statutory or voluntary sectors, should be available, together with equipment and training for supervised telerehabilitation. [2023]

Dysarthria is a neurological motor speech impairment that is characterised by slow, weak, imprecise and/or uncoordinated movements of the speech musculature and may involve respira ... Show more

Dysarthria is a neurological motor speech impairment that is characterised by slow, weak, imprecise and/or uncoordinated movements of the speech musculature and may involve respiration, phonation, resonance, and/or oral articulation. Impaired muscular control affects speech intelligibility, which is usually described as slurred or blurred. Dysarthria is common in the early stages of stroke, and is often associated with dysphagia (see Section 4.26 Swallowing ). [2016]

People with unclear or unintelligible speech after stroke should be assessed by a speech and language therapist to diagnose the problem and to explain the nature and implications to the person, their family/carers and the multidisciplinary team. [2016]

People with dysarthria after stroke which limits communication should:

be trained in techniques to improve the clarity of their speech;
be assessed for compensatory and augmentative communication techniques (e.g. letter board, communication aids) if speech remains unintelligible. [2016]

The communication partners (e.g. family/carers, staff) of a person with severe dysarthria after stroke should be trained in how to assist the person in their communication. [2016]

There are only two small RCTs on this topic, neither of which provides definitive evidence regarding treatment. Bowen et al (2012) included a planned subgroup of 66 people with dysarthria and Mackenzie et al (2014) was a feasibility study of 39 people. In the former, there was no significant difference between speech and language therapy and an attention control in the first few months after stroke, but a nested, qualitative study found that early, regular and frequent contact from a therapist or trained visitor was positively rated by people with stroke and their family/carers (Young et al, 2013). Mackenzie et al (2014) involved people with chronic dysarthria, and there was no difference in outcomes between individuals who received only speech practice and those who received speech practice and oro-motor exercises, although both groups improved over time. Participants were compliant with both interventions and many completed daily independent practice and reported an increase in confidence with treatment. There is little evidence to support the interventions in common use but there is some evidence of qualitative benefits (Palmer & Enderby, 2007). [2016]

A few people with stroke have specific and relatively isolated impairment of the ability to plan and execute the multiple skilled oral motor tasks that underlie successful talking ... Show more

A few people with stroke have specific and relatively isolated impairment of the ability to plan and execute the multiple skilled oral motor tasks that underlie successful talking ‒ this is apraxia of speech. It is usually associated with damage to the non-dominant hemisphere, and requires careful separation from aphasia and dysarthria. Interventions such as syllable level therapy and metrical pacing have been studied and the use of computers to increase intensity of practice has been suggested. [2016]

People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to maximise articulation of key words to improve speech intelligibility. [2016]

People with severe communication difficulties but good cognitive and language function after stroke should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech. [2016]

Studies in apraxia of speech are often small a Cochrane review (West et al, 2005) found no trials. There has been one subsequent crossover trial (Varley et al, 2016) which compared self-administered computerised communication therapy with a sham computerised treatment for people with chronic speech apraxia. Improvements in spoken word production (naming and repetition) were greater for the intervention group after the six week treatment but limited to trained single words. [2016]

Accessibility options:

Early, intense therapy for language problems after a stroke is linked to the greatest benefits

doi: 10.3310/nihrevidence_59653

This is a plain English summary of an original research article . The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Speech and language therapy helps people with language problems (aphasia) after a stroke. A large international analysis showed that this therapy is most effective when it is delivered early (within 28 days of the start of aphasia), frequently and in high doses. The greatest improvements in recovery were seen when people practiced tasks at home.

Aphasia is commonly caused by a stroke and can result in difficulty speaking, understanding speech, reading or writing. To date, there has been a lack of evidence about the how much therapy people with aphasia after a stroke need to support their recovery.

Researchers analysed 174 studies of speech and language therapy for aphasia after stroke. They found that the best recovery was linked to 20 – 50 hours in total of speech and language therapy. The best improvements in general language were linked to 2 – 4 hours of therapy, given over 4 to 5 days per week.

Optimal recovery for younger adults, men and people with milder aphasia was linked to more speech and language therapy. People under 55 years were likely to improve the most. However, the research showed that older people (75+ years) still improved with therapy.

The timing of therapy was important. Starting therapy within a month of experiencing aphasia was linked to the greatest improvements. People who had had aphasia for more than 3 months needed more therapy. However, people whose stroke occurred more than 6 months earlier could still improve with therapy.

Therapy could be effectively delivered in-person or via video. Family members who had received training from a speech and language therapist could support the delivery of a therapy programme to their loved one.

These findings have informed national and international guidelines. They are relevant to professionals who design and deliver programmes of speech and language therapy. People with aphasia after a stroke, and their carers, will also be interested.

For more information about aphasia, visit the NHS website .

This research features in our Collection: Improving stroke services: lessons from research. Read the Collection

What’s the issue?

More than 3.5 million people around the world have a stroke that affects their speech and understanding of speech, reading and writing (aphasia). Stroke patients with aphasia can struggle more with daily activities, and have poorer recovery and wellbeing than those who did not develop aphasia. Speech and language therapy improves people’s recovery, but therapists lack information on how to optimise the delivery of therapy for each individual.

This review brought together data from previous studies. Researchers assessed the impact of various types of treatment, delivered with greater or less intensity, and over different lengths of time.

What’s new?

The review included 174 studies from 28 countries (including 47 randomised controlled trials). Together, these studies included individual information on almost 6000 people.

Overall, the review concluded that for people with aphasia after stroke, their best recovery is associated with:

therapy started within 28 days of the onset of aphasia
20 – 50 hours of speech and language therapy in total
2 – 4 hours of therapy a week, delivered over 4 – 5 days, for general language improvement
tasks that are practiced at home.

Starting therapy early was important. People who had had aphasia for more than 3 months needed extra therapy to make their best recovery. However, those who had a stroke more than 6 months previously could still improve with therapy.

Younger adults (under 55) were likely to improve the most, though people over 75 still made gains with therapy. Men and people with milder aphasia were likely to need more therapy than others, the study found.

The intensity of therapy necessary varied according to the problem being addressed. The greatest improvements in overall language abilities and functional communication (the ability to communicate in real settings) were associated with 2 – 4 hours of therapy per week. But improvements in understanding speech were only evident when there were 9+ hours of therapy per week.

Neither the delivery method (in-person versus video, for example), nor who (professional therapist versus a family member who had received training from a professional therapist) delivered the speech and language therapy programme, made a meaningful difference.

Why is this important?

Overall, the greatest gains were linked to therapy that was delivered early (within 28 days of the start of aphasia), frequently and in high doses. Home practice and therapy tailored to the individual’s needs (and the level of their language difficulty) was linked with the greatest improvements.

Some of the studies in the review were small. The researchers noted variation in how data was collected and reported, including information about the people who took part, their aphasia (such as reading and writing problems) and the therapy delivered. Some of the findings therefore need to be interpreted with caution. Further research could explore groups of people unrepresented in the data, examine in more detail the link between dose of therapy and recovery, and develop more tailored speech and language therapies.

What’s next?

The findings have been included in the UK and Ireland National Clinical Guideline for Stroke and in Australian and New Zealand Clinical Guidelines. They are being considered by the National Institute for Health and Care Excellence (NICE) for its forthcoming update to guidelines on stroke rehabilitation in adults, and by the European Stroke Organisation Guidelines on Aphasia Rehabilitation after Stroke .

Privacy Overview

Whether a person has lasting disability after a stroke—and how much—depends on the size of the brain injury and the specific parts of the brain that are damaged. Rehabilitation is vital to stroke recovery. Stroke is the number one cause of serious adult disability in the U.S. and worldwide, but with treatment and rehabilitation, most people with stroke are able to recover some function. Ongoing research in this area has supported the development of several potential approaches and therapies to help rehabilitate people after stroke. Rehabilitation therapy often includes relearning or overcoming the loss of abilities like walking, processing language, and thinking clearly.

Source : American Stroke Association

Achieving the Best Long-Term Outcome

Although the brain can rewire its circuits after a stroke, improving function over months or years, rehabilitation can make a huge difference in helping survivors achieve the best long-term outcome.

Relearning Skills and Functions

Rehabilitation helps stroke patients relearn skills that are suddenly lost when part of the brain is damaged. It also prevents new medical problems from developing by using carefully directed repetitive practice. Research shows this repetitive practice—the same kind of practice used by all people when learning a new skill, like playing the piano or throwing a baseball—can help stroke patients.

Compensating for Lost Abilities

Rehabilitation also teaches stroke victims new ways to compensate for any remaining disabilities, such as learning to use only one hand or using assistive devices to compensate for speech and language challenges.

Therapy Often Starts Within 48 hours Rehabilitation therapy usually first takes place in the hospital within 48 hours of a stroke. It often starts with exercises to help overcome any paralysis or weakness. Recovering the ability to do basic activities of daily living is the first stage in the return to independence after having a stroke.

Professionals Who Specialize in Post-Stroke Rehabilitation

Rehabilitation nurses
Physical therapists
Occupational therapists
Therapeutic recreation specialists
Speech-language pathologists
Vocational therapists
Social workers
Psychologists

Rehabilitation Facilities

Many stroke survivors return home after discharge from the hospital, but some move into a medical facility or other rehabilitation program. The options are:

Devices to Support Stroke Recovery

The U.S. Food and Drug Administration (FDA) has approved several devices to support rehabilitation and recovery after stroke. For example, the Neurolutions Upper Extremity Rehabilitation System is used to increase range of motion and grasp in people age 18 and older with upper arm disability who are undergoing stroke rehabilitation. The brain-computer interface uses non-invasive electrodes to record brain activity. The electrode reading is then analyzed to determine the intended muscle movement, and a signal is sent to a wireless electronic hand brace, which in turn moves the person's hand.

The MicroTransponder Vivistim Paired VNS System electronically stimulates the vagus nerve, which runs from the brain down to the abdomen, to improve an individual's ability to move their arms and hands. The device is approved for use alongside stroke rehabilitation in people with moderate to severe impairments in their upper limbs and motor defects in their extremities caused by ischemic stroke. As technologies evolve, NINDS-funded researchers are exploring ways to leverage advancements in biologics to support people who have had a stroke.

Stroke Rehabilitation Projects

Another area of research focuses on using rehabilitation to stimulate the brain to rewire itself and compensate for functions lost as a result of stroke. NIH has funded more than 300 research projects involving stroke rehabilitation since 2012. NINDS and other NIH components conduct research on stroke rehabilitation and fund research at major institutions and universities. These are just a few examples:

The diagnosis and treatment of stroke-related swallowing problems (dysphagia) (through the National Institute on Deafness and Other Communication Disorders [NIDCD])
Developing new technology for stroke treatment and rehabilitation (through the National Institute of Biomedical Imaging and Bioengineering [NIBIB], collaborating with NINDS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development [NICHD])
Restoration of vision and rehabilitation (through the National Eye Institute [NEI])

Advancing Rehabilitation Through Technology

NIH is at the forefront of research advancing rehabilitation through technology, including:

Telerehabilitation

A home-based telehealth system designed to improve motor recovery and patient education after stroke. This Phase 2 trial found that intensive home-based daily upper extremity (UE) motor telerehabilitation significantly improved UE function in post-stroke patients and was not inferior to dose-matched therapy delivered in-clinic.

Transcranial Direct Current Stimulation for Post-stroke Motor Recovery

A Phase 2 study (TRANSPORT 2) to find out whether brain stimulation at different dosage levels combined with an efficacy-proven rehabilitation therapy can improve arm function.

Sleep SMART (Sleep for Stroke Management and Recovery Trial)

Determining whether treatment of sleep-disordered breathing with positive airway pressure after acute ischemic stroke or high-risk transient ischemic attack prevents recurrent stroke, and whether treatment of sleep-disordered breathing shortly after acute ischemic stroke improves stroke outcomes at 3 months.

Stroke Recovery Resources Additional information on recovery may be available from the following organizations and resources: American Stroke Association Brain Aneurysm Foundation Fibromuscular Dysplasia Society of America Hazel K. Goddess Fund for Stroke Research in Women Heart Rhythm Society Joe Niekro Foundation National Aphasia Association YoungStroke, Inc.

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Speech therapy and the benefits for stroke patients

Category: Speech Therapy , Stroke Recovery
Posted On: May 9, 2022
Written By: Allied Services Integrated Health

Speech-language pathologists (SLP) play an integral role in stroke recovery. Our work can be transformative, helping stroke patients recover their speech and with it, freedom of communication. Aphasia, dysarthria, apraxia of speech, and cognition impairments are commonly seen in people recovering from stroke, and can be assessed and treated by SLPs. Additionally, strokes can cause swallowing disorders that negatively impact quality of life. Here again, SLPs play an important role in assessing and treating stroke patients.

Restoring speech following stroke

Aphasia is a language impairment that can impact reading, writing, comprehension, and expression. Dysarthria and apraxia of speech are motor speech disorders: the result of a disconnect between the brain and speech mechanism. With dysarthria, the “plan” from the brain is correct, but the muscles can’t follow it due to weakness or incoordination, resulting in slurred or sluggish sounding speech. Apraxia of speech is the result of the brain's inability to create the “plan” to tell the muscles how to produce correct speech sounds. The muscles can follow the plan, but the plan is incorrect, resulting in difficulty producing the desired speech sounds to form the words they know they want to say. Every stroke patient presents differently, some experiencing one or more of these impairments while some may not experience any impairments requiring speech intervention.

Assessing and treating dysphagia

Dysphagia is a symptom of a medical condition, such as stroke, and refers to difficulty swallowing. The prevalence of dysphagia ranges from 50% to 80% in stroke patients. Addressing dysphagia is critical as it can lead to medical complications, nutrition and/or hydration issues, and a decrease in quality of life. The SLP is responsible for determining which diet texture a patient can safely tolerate considering the swallowing impairment and rehabilitating the swallow while minimizing risk of aspiration. Aspiration refers to food or liquid “going down the wrong pipe,” which we have all experienced at some point; however, repetitive occurrences are a concern for aspiration pneumonia, especially for those not in full health.

Gold standard in swallowing assessment

We cannot visualize the swallow after the food leaves the patient’s mouth; therefore, if a patient exhibits coughing or other signs of a pharyngeal impairment then a speech-language pathologist may conduct a videofluoroscopic swallow study. This is an an x-ray of the swallow. It is the gold standard for swallowing assessment and allows the SLP to evaluate the anatomy and physiology of the swallow to determine what is happening that is causing the patient to cough while eating or drinking, and create an individualized treatment plan.

Often, patients present with weakness within the region of the pharynx or delayed initiation of the swallow, where the food or liquid is propelled back into the pharynx before the swallow is triggered, causing that material to go “down the wrong pipe,” meaning into the airway rather than down the esophagus. Sometimes in these instances, a patient may temporarily be prescribed thickened liquids, as these travel slower than regular liquids and give the swallow a moment longer to trigger, decreasing aspiration risk, keeping the lungs clear and the patient safe. Dysphagia treatment can include diet modification, swallowing maneuvers to increase safety, and strength and coordination-based exercises to restore function.

Stimulating muscles for better swallowing

Today, many speech-language pathologists are certified in VitalStim, a neuromuscular electrical stimulation device that is FDA approved, non-invasive, and uses a controlled electrical current to help stimulate specific muscles responsible for swallowing. A dysphagia treatment session with application of VitalStim is ideally 60 minutes and includes various therapeutic exercises to target strengthening of specific musculature based on the swallowing impairments identified during the x-ray of the swallow. Surface electrodes are placed over specific swallowing muscles on the patient’s larynx and provide small electrical impulses to assist in contraction of the muscles, and over time, re-education of those muscles to restore the swallow.

About the Author: Amanda Petrosky, M.S., CCC-SLP , works with patients at Allied Services Scranton Rehab Hospital.

Stroke Recovery at Allied Services

Our inpatient and outpatient stroke rehab programs address physical, cognitive, behavioral, and socialization needs as well as identify and manage risk factors to help prevent future strokes. To learn more:

Scranton: 570-348-1360
Wilkes-Barre: 570-826-3900
Learn about stroke recovery here

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Open Access

Peer-reviewed

Research Article

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Medical Sociology and Rehabilitation Science, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

Roles Validation, Writing – original draft, Writing – review & editing

Roles Data curation, Formal analysis, Methodology, Validation, Writing – review & editing

Affiliations Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany, Institute of Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

Roles Formal analysis, Validation, Writing – original draft, Writing – review & editing

Affiliation Center for Stroke Research Berlin, NeuroCure Clinical Research Center and Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Daniel Schindel,
Lena Mandl,
Ralph Schilling,
Andreas Meisel,
Liane Schenk

Published: February 3, 2022
https://doi.org/10.1371/journal.pone.0263397
Peer Review
Reader Comments

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Citation: Schindel D, Mandl L, Schilling R, Meisel A, Schenk L (2022) Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis. PLoS ONE 17(2): e0263397. https://doi.org/10.1371/journal.pone.0263397

Editor: Marie Jetté, University of Colorado School of Medicine, UNITED STATES

Received: May 29, 2021; Accepted: January 18, 2022; Published: February 3, 2022

Copyright: © 2022 Schindel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Availability of data and materials: The data associated with the paper are not publicly available due to legal restrictions imposed by the health insurance companies providing the data (data contains potentially identifying patient information). The data set supporting the conclusions of this article are owned by German statutory health insurances, and are subject to strict data protection rules according to the German social security code. Therefore, the data cannot be made publicly accessible. The data we accessed is collected by health insurances when health providers bill their services towards the health insurance. The authors did not have special access privileges to the health insurances. To request the data please contact the four health insurances ( [email protected] , [email protected] , [email protected] , [email protected] ). To fulfill the legal requirements to obtain the data, researchers must obtain permission for a specific research question from the German Federal Social Insurance Office. Additionally, researchers must conclude a contract with the statutory health insurer regarding data access. The licensee is permitted to use the data for the purpose of the research proposal. Licensees are not allowed to pass the data to a third party, or to create Software or data bases with the exception of scientific publications. For assistance in obtaining access to the data, please contact the corresponding author (DS) or institution of the corresponding author ( [email protected] ).

Funding: LS recieved funding for this study through the German Federal Ministry of Education and Research [Project NAVICARE, 01GY1601, https://www.bmbf.de/ ]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Annually, 795,000 strokes occur in the US [ 1 ] and approximately 262,000 in Germany [ 2 ]. Common sequelae of left hemisphere strokes are speech impairments (dysarthria), language disorders (aphasia) and swallowing disorders (dysphagia), which are treated by speech and language therapy (SLT). It has been reported that 35–52% of patients experience dysarthria [ 3 , 4 ], 24–41% experience aphasia and 16–44% suffer from dysphagia during the inpatient phase of stroke care [ 3 – 5 ]. These findings are in line with studies stating that 32% of patients receive SLT within the first years after stroke [ 6 ]. Earlier studies found 29–45% of patients with dysphagia in the acute stage, 47% in rehabilitation and 17% after 4 months [ 7 ]. Dysphagia is associated with increased mortality due to malnutrition and aspiration pneumonia, and decreased quality of life due to tube feeding or dietary restriction [ 3 ]. The high vulnerability is also apparent in higher mortality rates, levels of dependency and likelihood of placement in a nursing home [ 5 ].

Clinical practice guidelines exist for the treatment of patients with aphasia, dysarthria and dysphagia, respectively [ 8 , 9 ]. Guideline-adherent treatment in the acute phase has a positive effect on the patients’ survival and independence after one year [ 10 ]. There is also evidence for the effectiveness of clinical guidelines in the inpatient post-acute rehabilitation of stroke: guideline adherence is associated with better recovery of physical function [ 11 ], with discharge home, with improvements on the Functional Independence Measure which includes items on communication [ 12 ], and with higher patient satisfaction [ 13 ]. However, stroke aftercare has been called a “black box” [ 11 ], as little is known about outpatient care in particular. Studies in the UK and Australia hint at limited outpatient provision and small-scale or infrequent therapies in case of chronic aphasia [ 14 , 15 ].

Prospective long-term studies demonstrate remaining comorbidities and complications in patients across a wide number of domains, with 47.0% of patients being in need of further stroke aftercare 41 months (study median) after stroke [ 6 ]. Figures for SLT provision are scarce, which limits the evidence base and impedes guideline development. One reason is that patients with language or speech disorders have a limited ability to provide information or even give consent. Therefore they are regularly underrepresented or excluded in research [ 16 , 17 ]. A claims data-based approach seems a suitable method to address that kind of selection bias and gain evidence in this hard-to-reach patient population.

Our first aim was to extract a set of testable parameters from current SLT and stroke management guidelines for aftercare treatment of aphasia, dysarthria and dysphagia. Secondly, the project aimed to analyse the current service provision of SLT in stroke aftercare and identify characteristics of those patients who are less likely to receive guideline-adherent care.

The sample is based on merged anonymous claims data of four statutory health insurance companies. Data were routinely collected without addressing a specific research question [ 18 ]. In total, the sample included 7,702 patients residing in a metropolitan German city who were admitted to hospital with a diagnosis of cerebrovascular disease (International Statistical Classification of Diseases and Related Health Problems German-Modification (ICD-10-GM): I60, I61, I62, I63, I64, I69, G45) in 2014. The sample used for our calculations consisted of 4,486 patients who received a diagnosis of either a specific speech disturbance (ICD-10-GM code R47, including the codes R47.0 (aphasia), R47.1 (dysarthria), and R47.8 (other and unspecified speech and language disorders)) or swallowing disorder (ICD-10-GM code R13 (dysphagia)) or any aftercare SLT. The utilisation of SLT was operationalised through the outpatient billing data from speech and language therapists. The data set comprises claims data reported for each patient one year before and one year after the initial stroke incident.

Ethics approval and consent to participate

Ethics approval was obtained from the ethics committee of the Charité –Universitätsmedizin Berlin on 24 July 2017 (EA2/095/17, chairperson PD Dr med. E. Kaschina).

Representativeness of data

For sample validation, the Berlin stroke registry was used [ 4 , 19 ]. In total, 12,006 stroke incidents were reported in the reference year 2014 [ 19 ]. Our sample linked four statutory health insurance funds, covering 64% of all events. The risk of unobserved selection bias is therefore reduced [ 20 ]. Our sample is older than the median age (78 vs. 75 years in the registry). The gender distribution differs, with women being over-represented in our sample (56.0% vs. 48.6% in the registry).

Guideline parameters to test for adherence

19 international guidelines for stroke management existed as of 2017 [ 8 , 9 ] which also contain recommendations for the rehabilitation of aphasia, dysarthria and dysphagia. The three highest-valued international guidelines were included in further considerations ( S1 Table ). In addition, aphasia, dysarthria and dysphagia recommendations were retrieved from six German-language guidelines that were previously identified through a systematic guideline appraisal [ 21 ]. Recommendations for outpatient dysphagia rehabilitation were extracted from the three German-language guidelines identified by an additional search, paralleling that described in Mandl et al. [ 21 ]. Where guideline updates existed, the latest version was used. Guideline adherence here means an observable implementation of the defined recommendations. Extraction of parameters to test adherence using claims data was conducted by three scientific researchers: an experienced speech therapist, a medical doctor, and a medical sociologist. In a first step, all concrete and specific recommendations were extracted from each guideline. Second, comparable recommendations were grouped together, and the verifiability of the results was discussed in a consensus session.

In total, five specific testable parameters for SLT provision were extracted from the guidelines ( Table 1 ): Patients showing speech and language disorders should be treated by professional speech and language therapists (Parameter 1: speech therapists). To account for spontaneous remission and early inpatient therapy of disorders [ 22 – 24 ], we defined having at least two specific diagnoses of speech disturbance (ICD-10-GM code R47, including aphasia (ICD-10-GM code R47.0), dysarthria (ICD-10-GM code R47.1), and “other and unspecified speech and language disorders” (ICD-10-GM code R47.8)) or swallowing difficulties (dysphagia (ICD-10-GM code R13)) during inpatient or outpatient care as the prerequisite for determining a need of aftercare SLT.

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https://doi.org/10.1371/journal.pone.0263397.t001

The following parameters consider the quality of SLT and therefore refer exclusively to those patients who received therapy. For these patients, comprehensive diagnosis is recommended (Parameter 2: specific diagnosis). The assumption is that coding a disease presupposes diagnosis. Patients receiving SLT were divided into two groups: those with a distinct ICD-10-GM code (R13, R47), and patients with a generic diagnosis code for stroke (G45, I60-I65).

In addition, guidelines recommend early initiation and continuity of treatment (Parameter 3: continuity). The time gap between inpatient discharge from hospital or rehabilitation to initiation of aftercare speech therapy should be as short as possible. We calculated a continuous variable for the number of days without therapy.

Next, the guidelines recommend a high intensity of treatment, which we equated with longer therapy sessions (Parameter 4). The German health care system provides for therapy sessions of 30, 45 or 60 minutes. Based on the guideline recommendations, we defined a binary variable distinguishing between shorter (< 60 minutes) vs. longer (60 minutes) duration of sessions.

Another recommendation specifies higher frequencies of at least 2 sessions per week during the post-acute phase as preferable (Parameter 5: frequencies). We received individual dates for the therapies from only two health insurance companies (n = 3,339). To measure frequency, we calculated the average days between the therapy sessions ( Table 1 ).

Finally, a total score derived from test parameters 1 to 4 was determined for the total sample (Guideline Adherence Score/GAS). The metric test parameter 3 was dichotomised at the median beforehand for this purpose. Overall, the score permits values between 0 and 4, with a higher score implying a higher level of guideline adherence ( Table 1 ).

Independent variables for characterization of patients

To characterise the patients, information on age [continuous], gender [male/female] and duration of health insurance [dropout date] were taken into account. In addition, a dichotomous variable was prepared to identify strokes in the year previous to the first stroke included in our data [prior]. Patients were categorised according to the type of their initial stroke in the observation period, independent of possible subsequent recurrences with other stroke types. To measure the existing co-morbidity burden, the age-adjusted Charlson Comorbidity Index (CCI) was prepared at the time of the initial stroke included in our data. The test serves to estimate morbidity and mortality of patients based on 19 prognostically relevant comorbidities [ 25 – 27 ]. We used the duration of hospital stay for the initial stroke in 2014 as an indication of the severity of the stroke [severity]. In this context, patients who stay for 8 or more days are classified in the severely affected group [ 28 , 29 ]. The selection of relevant comorbidities is based on previous work by Van den Bussche et al. [ 30 ] and on treatment experience in relation to frequent SLT for underlying morbidities that influence the therapy.

Data analysis

To describe the data set, the frequencies in the total sample and in the groups of stroke patients with and without SLT were descriptively analysed using the chi squared test. Due to the low number of cases, Fisher’s Exact Test was used to compare rehabilitation diagnoses. Ordinal and metrically scaled variables were calculated using Median and Interquartile Range (IQR), and the Mann Whitney U-test (Wilcoxon Rank Sum test) and Student’s t-Test were performed to test for differences between the groups. The five test parameters and the Guideline Adherence Score are described in analogue form. Where more than two group means were to be compared, univariate factorial analysis was used.

We performed multivariate logistic and linear regression analyses in order to test whether effects persisted after controlling for covariates. The five defined test parameters plus GAS functioned as target variables. We calculated odds ratios (OR) with 95% confidence intervals (95% CI). The software package SPSS version 25.0 was used for our statistical analysis. The significance level was set at p<0.05.

Sample characteristics

The study population comprised a total of 4,486 stroke patients. Of these, 90.3% were diagnosed with dysarthria, aphasia or dysphagia and 44.1% had received outpatient SLT within the first year after the initial stroke ( Table 2 ). The proportion of women was 56.0%. The median age was 78 years.

https://doi.org/10.1371/journal.pone.0263397.t002

Patients with SLT

Less than half of the patients included in the study received aftercare SLT (44.1%, Table 2 ). Factors significantly associated with receiving SLT were a haemorrhagic stroke, higher comorbidity burden (Charlson Index, CCI), secondary diagnoses of paralysis, depression, Parkinson’s, insomnia, incontinence and a long initial hospital stay (severity) ( Table 2 ). Patients following transient ischemic attacks (TIA) less often received outpatient SLT. In addition, patients who were in inpatient rehabilitation after stroke were more likely to get SLT aftercare. With increasing rehabilitation duration, the likelihood of receiving SLT also increased.

Description of test parameters

Women less frequently received specific speech, language or swallowing disorder diagnoses and less frequently had long treatment sessions compared to men. Speech therapists were less often involved in older patients’ SLT aftercare. If SLT was applied, the treatment started earlier with increasing patient age. Similar observations were made for patients who had had a stroke in the previous year. Patients with a high Charlson Index score were shown to receive less continuity of care and shorter therapy duration ( Table 3 ). On average, patients received one SLT session per week.

https://doi.org/10.1371/journal.pone.0263397.t003

Speech therapists (Parameter 1)

Model 1 shows, while controlling for additional influencing factors, that in addition to a stroke in the previous year (OR 1.66 [95%CI: 1.06/2.6], p = 0.025), the greater severity of the stroke (OR 1.57 [95%CI: 1.18/2.08], p = 0.002) and also the presence of paralysis (OR 1.17 [95%CI: 1.08/1.3], p<0.001) increase the chance of a speech therapist giving treatment ( Table 4 ).

Hierarchical logistic regression models (backwards with likelihood-ratio-statistics).

https://doi.org/10.1371/journal.pone.0263397.t004

Specific diagnosis (Parameter 2)

According to the multivariate model, female stroke patients who received speech therapy had a lower chance of receiving a specific impairment diagnosis than male patients (OR 0.70 [95%CI: 0.55/0.88], p = 0.003) ( Table 4 ). Equally, the predicted chances of receiving a specific diagnosis were lower for patients with transient ischemic attack compared to other types of stroke. Patients with ischemic stroke, more severely affected patients, and those with paralysis had greater chances of a specific impairment diagnosis. The likelihood of a specific disorder diagnosis was also increased for patients with a post-stroke depression (OR 1.42 [95%CI: 0.95/2.26], p = 0.084).

Continuity (Parameter 3)

Increasing age, a stroke event in the previous year, and the occurrence of paralysis increased the likelihood of receiving earlier SLT and therefore more continuous aftercare after discharge from an acute hospital or inpatient rehabilitation centre (p>0.034, Table 5 ).

Linear regression models (for continuous dependent variables).

https://doi.org/10.1371/journal.pone.0263397.t005

Duration of sessions (Parameter 4)

In the multivariate model, being female (OR 0.64 [95%CI: 0.43/0.94],p = 0.022) and a higher Charlson Index (OR 0.89 [95%CI: 0.80/0.99], p = 0.032) were associated with a reduced chance of receiving longer therapy sessions of 60 minutes ( Table 4 ).

Frequencies (Parameter 5)

Higher frequencies in therapies were observed for patients with more severe stroke. In contrast, less frequent SLT was associated patients with a TIA as initial stroke in the observation period ( Table 5 ).

Guideline adherence score (GAS)

Higher probabilities of simultaneous implementation of several guideline recommendations were to be expected with increasing patient age (Beta 0.105, p = 0.03). Other predictors that made guideline adherence more or less likely were not identified ( Table 5 ).

The findings shown provide important initial indications of guideline adherence in stroke aftercare of dysarthria, aphasia and dysphagia. As measured by the defined test parameters, we observed some disadvantageous deviations from guideline recommendations in the case of female patients, patients with severe stroke (as captured by hospitalization duration) and higher rates of comorbidities. Further, women were less likely to receive specific disorder diagnoses and longer therapy sessions. In the case of younger patients, more time elapsed before the take-up of aftercare speech therapies. In addition, patients of older age were less likely to use SLT aftercare than younger patients. A deeper look into the data shows that the implementation of recommendations is not necessarily related to specific patient groups per se. While some recommendations are implemented well, others for the same group might appear to be in great need of improvement.

As we have shown, patients who receive SLT are often in a poorer state of health and have a higher comorbidity burden than patients with no SLT. For example, our findings confirm observations of previous studies that report frequent occurrence of dementia disorders and depression after strokes [ 31 , 32 ]. In our sample, the group receiving SLT was also disproportionally often diagnosed with insomnia. The comorbidities mentioned may make it more difficult to implement guideline recommendations, because patients’ ability to cooperate may be reduced due to the progressive course of dementia or their willingness to cooperate may be impeded due to low spirits and a depressive state [ 33 ].

Speech therapists

The majority of patients with multiple diagnosis of specific speech, language, and swallowing impairments receives aftercare through speech and language therapists. Previous studies and registers reported high inpatient therapy quotas, showing that as many as over 90% of patients received comprehensive testing and early application of SLT during their inpatient stay [ 4 , 5 ]. A large-scale British study reported that 77% of patients required SLT, and this was also provided for 98% of these patients during their stay in hospital [ 5 ]. However, one patient in four was discharged from hospital to their homes with impairments and very little is known about aftercare utilization among this group [ 5 ]. In an earlier study, Code et al. observed a decline in the utilization of SLT after discharge compared with treatment in hospital and rehabilitation centres [ 14 ]. In this study, the higher level of guideline adherence observed in aftercare in cases of severe stroke, paralysis and the occurrence of stroke in the previous year pointed to better implementation of the guideline recommendations in the case of highly vulnerable groups. Patients with less severe stroke or following an initial stroke less frequently received SLT aftercare, or made use of such a therapy, despite a relevant diagnosis. In this context we should bear in mind that aphasia has been found to have a higher impact on health-related quality of life than cancer and Alzheimer’s disease [ 34 ], and, unsurprisingly, both aphasia and dysarthria have a negative impact on social participation [ 34 – 36 ]. A possible explanation might be competing priorities after discharge where in most cases, patients have to organize their complex care alone. A current study claims that older stroke survivors prioritise improving their balance and walking problems above aphasia or speech difficulties, which might explain the reduced utilization of aftercare SLT [ 37 ]. Studies show that even after leaving hospital, the majority of stroke patients still demonstrate a comprehensive need for treatment that is largely not fulfilled [ 6 ]. Contributing structural factors include the fact that organising aftercare can be overtaxing or frustrating [ 38 ] and the shortage of treatment places due to the increasing lack of trained staff in this professional field [ 39 ]. Multiple factors such as social determinants (lack of transportation, access to community service, financial situation), social support (family support, community support) and issues within the health system (disconnect between services and sectors) mean that the group of stroke patients, usually older people, must be viewed as particularly complex, and individual support needs can vary greatly [ 40 ]. The failure to address these disorders through specialists after inpatient discharge needs further examination.

Specific diagnosis

A prerequisite for appropriate treatment is a prior comprehensive diagnosis resulting in the provision of diagnoses that are as specific as possible. Specific diagnoses have been made beforehand for the majority of patients who received SLT aftercare. It is striking, however, that the available data show a comparatively lower level of specific diagnoses for female stroke patients. A range of gender-related differences in care are documented even at an early stage in intensive care [ 29 , 41 , 42 ]. For example, female patients more frequently report atypical symptoms, resulting in a less prompt stroke diagnosis that comes too late for thrombolytic therapy [ 42 ]. Undiagnosed and untreated pre-existing conditions, such as high blood pressure, occur more often in the group of women patients, also making them less suitable for thrombolytic therapy [ 42 ]. On the other hand, older age when the stroke occurs, linked with more frequently living alone, are associated with slower awareness of symptoms and later arrival in hospital. As a result, worse functional outcomes and more frequent impairments [ 41 ], lower quality of life [ 43 ] and higher levels of hospital mortality [ 29 ] are observed among female patients. There is often a need for post-inpatient therapy [ 6 ], but lower social status and smaller social networks seem to make this more difficult to address [ 17 ]. To explain the lower level of guideline adherence observed for female patients in relation to aftercare SLT, supplementary primary data are required to characterise them in more detail.

Early initiation and continuity

One aspect of guideline-adherent therapy after stroke is early therapy initiation for stroke patients after hospital discharge. We found that half of the patients began aftercare within just under two weeks, with older and severely affected patients tending to start treatment faster. A study from New Zealand found comparable mean delays of 14 days until SLT initiation [ 44 ]. Minorities and persons with inadequate health insurance were less likely to receive SLT within this period [ 45 ]. Other studies stated that the initiation of therapy for the majority of patients took place after 6 weeks, with patients being particularly dissatisfied with the low amount of outpatient therapy provision [ 46 ]. In line with our results, an earlier study found that patients with aphasia who needed domiciliary visits received less therapy and at a later stage after hospital discharge than their more mobile peers [ 47 ]. Small social networks might complicate the organization of early initiation and continuity of care [ 17 , 41 ]. The way service provision and claims are organised in the German health care system may help explain the quicker initiation of outpatient aftercare in Germany compared to the situation in other countries. Patients with statutory health insurance usually receive a prescription for outpatient speech and language therapy from their GP. The prescription expires if the relevant outpatient aftercare treatment does not begin within 14 days. Other possible reasons behind the relatively rapid initiation of aftercare in Germany are local supply advantages due to the urban location of the study and the general obligation to hold health insurance in Germany.

Duration of sessions

The majority of patients receives shorter therapy sessions than recommended in the guidelines. According to the guidelines, therapy should be “as tolerated and feasible” according to the patients’ state of health [ 48 ]. This seems to provide a possible explanation for the lower likelihood of longer therapy sessions shown in our data for the group of patients with a higher comorbidity burden. We found no explanation as to why the majority of probably more robust female patients also receive shorter therapy sessions. International studies also report that therapy sessions in practice are shorter than recommended in clinical guidelines [ 5 ]. Both frequency and duration of sessions might be improved using telemedicine options. Preliminary studies show high levels of participation in telemedicine provision among the group of women identified as vulnerable, due to the expectation of shorter waiting times, and more frequently report greater patient satisfaction [ 49 , 50 ].

Frequencies

A further recommendation found in different guidelines was that SLT should be provided with high frequency of at least 2 sessions per week. Our results indicate a lower frequency and therefore inadequate provision. Code et al. reported equivalent findings for the UK with an average of 1–1.5 hours/week treatment for chronically aphasic people attending aftercare services [ 14 ]. Low frequencies of aftercare aphasia therapy have been reported previously [ 15 , 47 , 51 – 54 ]. Patients needing domiciliary visits [ 47 ], patients in aged care, and those treated in private practices [ 54 ] were most at risk of under-provision. We confirm the clear gap between practice patterns and research evidence that has previously been addressed elsewhere [ 53 ]. An opposing argument against high frequency therapy was reported in Brady et al., stating that patients more often stop attending high-intensity therapy [ 55 ].

The overall view shows that under this parameter, the majority of patients who required SLT were not given care in line with the guideline recommendations. The observed “age effect” underlines the attention paid by care providers when dealing with older patients. According to that, the worse physical and mental health associated with age [ 43 ] may possibly promote guideline-adherent care.

Guideline adherence visibility in claims data

Evidence exists that clinical guidelines can improve outcomes of treatment conducted by both medical doctors [ 56 ] and by professions allied to medicine [ 57 ]. Beside bridging the research-practice gap, clinical guidelines are meant to reduce inappropriate variation in health care provision [ 58 ], thus improving health care equity. Ever since there have been guidelines, their implementation into clinical practice and guideline adherence have been an issue [ 59 ]. To our knowledge, no study has yet explicitly and comprehensively analysed whether and to what extent the provision of aftercare SLT adheres to current guidelines regarding the rehabilitation of aphasia, dysarthria and dysphagia after stroke. The analysis of health insurance claims data has been successfully applied previously to investigate guideline adherence and the influence of patient characteristics, for instance in patients with chronic coronary heart disease and peripheral arterial disease [ 60 , 61 ]. There were attempts in Japan to use claims data to develop quality indicators for stroke treatment [ 62 ]. Our study contributes the usability of claims data for health care services analysis even in an aftercare setting and for hard-to-reach patients, due to their communication restrictions, while providing conceivable indicators for SLT.

Clinical relevance

The data presented here suggest that guideline adherence in outpatient follow-up of speech, language, and swallowing disorders after stroke requires significant improvement. For example, neither the guideline-recommended therapy frequencies nor the recommended 60-minute duration of therapy sessions are frequently achieved. In addition, the interval of approximately 2 weeks between discharge from the hospital and initiation of SLT treatment measures in outpatient follow-up is too long. Less than two-thirds of patients with repeatedly diagnosed speech and language disorders during acute inpatient stay were subsequently treated by outpatient SLT. The highest adherence to guidelines was observed when a specific diagnosis (as a prerequisite for SLT) was present. Structures and processes need to be established that can ensure guideline-adherent treatment of these patients in clinical practice according to their specific needs.

Limitations

The secondary data used for this study were originally collected for the purpose of settling accounts between health insurance companies and service providers, not for scientific purposes. They are in principle suitable to reflect the care provided–with no recruitment bias. The logic of the data origin, however, means that there is a chance that patients with relevant impairments who need SLT, but who received no diagnosis or care, were not considered. The issue of large scale undercoding of diagnoses in administrative date has previously been mentioned elsewhere [ 63 ]. The authors’ approach of operationalising the severity of the stroke using the duration of the initial stay in hospital (LOS) is tried and tested; however, as an individual indicator it is rather too general. A previous need for care or pre-existing conditions are as likely to cause longer hospital stays as a severe stroke. If present, a combination of additional indicators for LOS (e.g., sequelae (hemiplegia, neurological neglect), change in nursing care (e.g., to level 3 for the first time after stroke)) is recommended [ 28 ]. Where further indicators are available, e.g., in the form of the Stroke Severity Index, they should also be taken into account [ 64 , 65 ]. Statements on the adequacy of treatment are only possible to a limited extent. An apparent insufficiency in care provision, for example, may reflect the patients’ preferences or may be oriented on patients’ endurance limits, type of therapeutic stimulus or contraindications in the patient [ 66 ]. A lower level of patient take-up may be due to improved health with a concomitant reduced requirement, or to a lack of social networks and depressive episodes. The lack of specific diagnoses should be discussed because in practice, SLT is also prescribed without a specific diagnosis, simply based on the indication of a general stroke diagnosis. The comprehensive diagnosis is then carried out by the SLT therapists, whose diagnoses are not visible in the claims data. On the other hand, patients with multiple diagnoses who receive no SLT need not necessarily be viewed as inadequately provided for. Depending on the initial severity, lesion location and lesion size, spontaneous recovery is possible [ 22 – 24 ].

The suggested test parameters are an attempt to make existing guideline recommendations visible in secondary data. In many cases, guidelines do not include very concrete recommendations, which made it more difficult to develop reliable test parameters. One issue is that the structure of claims data limits the detailed operationalising of test parameters and a range of guideline recommendations cannot be reflected in the available claims data. This applies, for example, to the involvement and coaching of family members, or participation in self-help groups. In addition, health insurance companies give no information about the content and quality of specific therapeutic training or the patients’ subjective motivation and satisfaction. Finally, we should note that the analyses are based on data from statutory health insurance companies. Patients with private insurance—who comprise only 10% of all health insurance holders in Germany, however—are therefore not included in the sample.

These findings provide important initial indications for guideline adherence in the aftercare of dysarthria, aphasia and dysphagia following stroke. The suggested test parameters and the total score represent an attempt to draw aftercare treatment of speech impairments into clearer focus for future research. Continuous monitoring of the implementation of guideline recommendations may help to systematically identify disparities in care and to optimise treatment in a targeted way. Initial research findings suggest that telemedicine provision is suitable as a supplement to previous face-to-face treatment provision in order to provide targeted treatment.

Supporting information

S1 table. overview of guidelines included in the parameter construction..

https://doi.org/10.1371/journal.pone.0263397.s001

Acknowledgments

The authors thank Christoph Poggendorf for his considerable efforts in organising and preparing the data set. In addition, we would like to thank the AOK Nordost, Techniker Krankenkasse, BARMER and DAK-Gesundheit for their cooperation and provision of anonymous health insurance data.

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18. Spasoff RA. Epidemiologic methods for health policy: Oxford University Press; 1999.
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58. Field MJ, Lohr KN. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: The National Academies Press; 1990. 168 p.

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Neurological problems

How we can help people who have had a stroke

A stroke happens when the blood supply into the brain is cut off. Without this supply, brain cells can be damaged and destroyed as nutrients and oxygen will not reach the cells and will not be able to function as normal. This is known as an attack of the brain.

Speech and language therapy can treat and support any speech, language, communication and swallowing difficulties caused by a stroke. Speech and language therapy will provide an individualised therapy programme to help improve and support communication and swallowing difficulties.

What is a stroke?

A stroke is an attack on the brain when the blood supply to the brain is cut off. This can either be through a blood clot or a burst blood vessel. In the UK, every year roughly 145,000 people have a stroke. It is more common in people over 65 however can occur at any age. It is important to note, that a stroke affects people in many different ways and varies in severity.

A stroke can affect speech, movement, memory and thought processes. The extent of damage will depend upon which part of the brain is affected, as well as the health of the person before the stroke.

The two hemispheres of your brain affect different functions of your body. For example; the right side of the brain will control the left side of your body. Therefore damage to the right side of your brain will mean problems with the left side of your body. Language, talking, writing and reading are all controlled in the left hemisphere of the brain. Perceptual skills and spatial awareness are controlled in the right hemisphere.

There are two types of stroke, an ‘ischaemic stroke’ or a ‘haemorrhagic stroke’.

Ischaemic stroke

An ischaemic stroke is a blockage to an artery carrying blood to the brain. Causes can vary from a blood clot, air or fat bubble in the blood vessel or main artery. This is the most common cause of stroke.

Haemorrhagic stroke

A haemorrhagic stroke is the bursting of a blood vessel resulting in bleeding into the brain. This hemorrhage may be caused by either a vessel bursting in the brain, or a vessel bursting on the surface and leaking into the area between brain and skull.

Another cause of a stroke includes a ‘transient ischaemic attack’.

Transient ischaemic attack

A transient ischaemic attack occurs when the brain has the blood supply interrupted for a brief amount of time. Commonly known as a mini stroke, the symptoms are the same as a normal stroke, however only last for a maximum 24 hours. This could be a warning sign that the brain is not getting enough oxygen and so may lead to a more serious form of stroke.

What causes a stroke?

The cause of a stroke is a blood clot or bleed into the brain. This cuts off the supply of oxygen to the brain and does not allow it to function properly. There are a number of risk factors associated with a stroke. Some of these can be changed but some cannot. Things such as age, family history and ethnicity are non-changeable risk factors. Manageable risks are things such as; high blood pressure, diabetes and high cholesterol.

What problems caused by a stroke can SLT UK help with?

SLT UK can help with a number of problems arising after a stroke. Depending upon which type of stroke someone has had, a speech and language therapist will tailor therapy to suit each patients needs.

Our speech and language therapists can help individuals who have had a stroke with attention and listening problems, communication problems, swallowing difficulties, voice and speech problems.

There are many benefits to having speech and language therapy after a stroke, speech therapy will improve a patient's communication. This may, in turn, increase the patient's confidence, independence and relieve the stress and anxiety after stroke.

How does speech and language therapy help with a stroke?

Speech and language therapy can help with the effects of a stroke and improve on many different associated difficulties. This includes, swallowing, eating, drinking and associated language problems.

After a stroke, many people have difficulties with their language. This is known as aphasia, either expressive which involves not being able to find the right words or receptive which is the understanding of words. It is possible to have a mixture of each type. If difficulties are more to do with the formation of words, this is known as dysarthria. This is when the stroke affects the movement in your face, tongue or throat.

If the right hemisphere is affected this can be termed right hemisphere communication disorder. Right hemisphere communication disorder can often go unnoticed as it doesn’t directly affect speech or language. Instead it affects how an individual uses language in everyday social situations, known as social communication. An individual’s ability to take turns in conversation, attention and ability to concentrate can be affected.

What would speech and language therapy treatment for a stroke involve?

Speech and language therapy treatment for a stroke will involve trying to build upon the parts of the brain which are affected and help to compensate and improve associated problems of a stroke. An initial assessment will be done to decide upon the best type of treatment and treatment that is specific.

Speech and language therapy may involve assessment, reports, reviews, therapy programmes, support groups and advice or education.

Specific treatment for difficulties after stroke may also include:

Stroke rehabilitation group
Social skills group
Total communication approach
Articulation therapy

A stroke is caused by a blockage or burst blood vessel in the brain. This leads to a lack of oxygen, and causes the brain not to function as it should. A stroke is individual and will depend upon where the blockage is as to what is affected. Speech and language therapy can be extremely beneficial to someone who has had a stroke.

If you feel you may benefit from speech and language therapy or would like any more information on our services please email [email protected] or call 0330 088 5643.

Worried about your communication.

If you are worried about any aspect of your speech, language and communication, do not hesitate to contact us to speak to one of our passionate speech and language therapists.

Home visits

We are able to provide therapy in a place and time that is most suitable for you and your needs, including home visits.

Book a free telephone consultation

We offer a free telephone consultation in order to discuss any concerns regarding your speech, language, voice or swallowing.

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5 things to know about stroke

Mayo Clinic Staff

Here are five key things to know about stroke:

1. strokes affect the oxygen and nutrients supplied to your brain..

Strokes occur when nutrients and oxygen are not delivered to the brain through blood vessels, leading to the death of brain cells. This lack of delivery can be caused by a clot in a blood vessel obstructing the blood flow to the brain, known as an ischemic stroke, or when a blood vessel ruptures and prevents blood flow to the brain, known as a hemorrhagic stroke.

Sometimes, the obstruction to the blood flow and the resulting symptoms are caused by a temporary clot and are transient, resulting in a mini-stroke or transient ischemic attack, or TIA.

2. Strokes can happen to anyone.

Strokes can happen to anyone regardless of age, gender or race. Certain risk factors can put you at a higher risk of stroke .

Risk factors are divided into two categories:

Controllable — the ones you can control or improve
Uncontrollable — those that are not within your control

Common controllable risk factors include:

Atrial fibrillation, which increases stroke risk by five times
Excessive alcohol intake — an average of more than one drink per day for women or more than two drinks a day for men
High blood pressure
High cholesterol
Illicit drug use
Obstructive sleep apnea
Physical inactivity
Sickle cell anemia
Smoking or vaping

Uncontrollable risk factors include:

Increasing age

3. Be prepared to spot the signs of a stroke.

Learn to recognize the signs of stroke quickly.

The American Stroke Association lists these symptoms to help you know when to seek medical care:

F = Face drooping: Ask the person to smile and see if the smile is uneven.
A = Arm weakness: Ask the person to raise both arms and see if one arm drifts down.
S = Speech difficulty: Ask the person to speak and see if the speech is slurred.
T = Time to call 911: Stroke is an emergency. Call 911 at once. Note the time when any of the symptoms first appear.

Other stroke symptoms to watch for include:

Numbness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or difficulty understanding speech
Sudden onset severe headache with no known cause
Sudden vision issues, such as trouble seeing in one or both eyes
Trouble walking, loss of balance, dizziness or coordination

If you or someone you are with have any stroke-like symptoms, seek immediate medical care.

4. A stroke is a medical emergency.

Every second counts when someone is experiencing a stroke. Once a stroke starts, the brain loses around 1.9 million neurons each minute. For every hour without treatment, the brain loses as many neurons as it typically does in nearly 3.6 years of regular aging.

While waiting for paramedics, do these things if possible:

If the person is conscious, lay them down on their side with their head slightly raised and supported to prevent falls.
Loosen any restrictive clothing that could cause breathing difficulties.
If weakness is obvious in any limb, support it and avoid pulling on it when moving the person.
If the person is unconscious, check their breathing and pulse, and put them on their side.
If they do not have a pulse or are not breathing, start CPR straight away.
Do not give them anything to eat or drink if you feel they may have trouble swallowing.

5. Women have an increased risk of stroke.

According to the American Stroke Association, stroke is the third most common cause of death in women. Over 90,000 women die from a stroke in the U.S. each year. Every 1 in 5 women will have a stroke , and about 55,000 more women than men have a stroke each year, with Black women having the highest prevalence of stroke.

The risk of stroke increases in women who have atrial fibrillation, migraines with aura, smoke, take birth control pills, use hormonal replacement therapy, are pregnant or have preeclampsia.

Talk to your healthcare team about your stroke risk and ways to lower your risk by addressing controllable factors.

Prashant Natteru, M.B.B.S., M.D. , is a neurologist in La Crosse , Wisconsin.

This article first published on the Mayo Clinic Health System blog .

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Speech and language therapy for aphasia following stroke

Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and writing. Approximately one third of people who have a stroke experience aphasia.

To assess the effects of speech and language therapy (SLT) for aphasia following stroke.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015), MEDLINE (1946 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), AMED (1985 to September 2015), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015). We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015), the Stroke Trials Registry (to 21 September 2015), Current Controlled Trials (to 22 September 2015), and WHO ICTRP (to 22 September 2015). In an effort to identify further published, unpublished, and ongoing trials we also handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles, and we contacted academic institutions and other researchers. There were no language restrictions.

Selection criteria

Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) versus no SLT; social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); or another SLT intervention (differing in duration, intensity, frequency, intervention methodology or theoretical approach).

Data collection and analysis

We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.

Main results

We included 57 RCTs (74 randomised comparisons) involving 3002 participants in this review (some appearing in more than one comparison). Twenty‐seven randomised comparisons (1620 participants) assessed SLT versus no SLT; SLT resulted in clinically and statistically significant benefits to patients' functional communication (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.49, P = 0.01), reading, writing, and expressive language, but (based on smaller numbers) benefits were not evident at follow‐up. Nine randomised comparisons (447 participants) assessed SLT with social support and stimulation; meta‐analyses found no evidence of a difference in functional communication, but more participants withdrew from social support interventions than SLT. Thirty‐eight randomised comparisons (1242 participants) assessed two approaches to SLT. Functional communication was significantly better in people with aphasia that received therapy at a high intensity, high dose, or over a long duration compared to those that received therapy at a lower intensity, lower dose, or over a shorter period of time. The benefits of a high intensity or a high dose of SLT were confounded by a significantly higher dropout rate in these intervention groups. Generally, trials randomised small numbers of participants across a range of characteristics (age, time since stroke, and severity profiles), interventions, and outcomes.

Authors' conclusions

Our review provides evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, reading, writing, and expressive language compared with no therapy. There is some indication that therapy at high intensity, high dose or over a longer period may be beneficial. HIgh‐intensity and high dose interventions may not be acceptable to all.

Plain language summary

Speech and language therapy for language problems after a stroke

Review question

We reviewed the evidence of the effect of speech and language therapy (SLT) on language problems experienced by people after a stroke (known as aphasia).

About a third of people who suffer a stroke develop aphasia. One or more areas of communication can be affected: speaking, oral comprehension, reading, and writing. Speech and language therapists assess, diagnose, and treat aphasia at all stages of recovery after stroke. They work closely with the person with aphasia, families, and other healthcare professionals. We wanted to see whether SLT for aphasia was effective and whether it was better or worse than non‐specialist social support. We also wanted to see which approaches to therapy offered the best recovery.

Study characteristics

The evidence is current to September 2015. We found and included 57 studies involving 3002 people with aphasia in our review. We reviewed all SLT types, regimens, and methods of delivery.

Key results

Based on 27 studies (and 1620 people with aphasia), speech and language therapy benefits functional use of language, language comprehension (for example listening or reading), and language production (speaking or writing), when compared with no access to therapy, but it was unclear how long these benefits may last.

There was little information available to compare SLT with social support. Information from nine trials (447 people with aphasia) suggests there may be little difference in measures of language ability. However, more people stopped taking part in social support compared with those that attended SLT.

Thirty‐eight studies compared two different types of SLT (involving 1242 people with aphasia). Studies compared SLT that differed in therapy regimen (intensity, dosage and duration), delivery models (group, one‐to‐one, volunteer, computer‐facilitated), and approach. We need more information on these comparisons. Many hours of therapy over a short period of time (high intensity) appeared to help participants' language use in daily life and reduced the severity of their aphasia problems. However, more people stopped attending these highly intensive treatments (up to 15 hours a week) than those that had a less intensive therapy schedule.

Quality of the evidence

Generally, the quality of the studies conducted and reported could be improved. Key quality features were only reported by half of the latest trials. Thus, it is unclear whether this was the result of poorly conducted studies or poorly reported studies. Most comparisons we made would benefit from the availability of more studies involving more people with aphasia.

Summary of findings

Description of the condition.

The term aphasia (less commonly referred to as dysphasia) is used to describe an acquired loss or impairment of the language system following brain damage ( Benson 1996 ). Usually associated specifically with language problems arising after a stroke, it excludes other communication difficulties attributed to sensory loss, confusion, dementia or speech difficulties due to muscular weakness or dysfunction, such as dysarthria. The most common cause of aphasia is a stroke (or cerebrovascular accident), mainly to the left hemisphere, where the language function of the brain is usually situated for right‐handed people. About a third of all people who experience a stroke develop aphasia ( Engelter 2006 ; Laska 2001 ). The aphasic population is heterogeneous, with individual profiles of language impairment varying in terms of severity and degree of involvement across the modalities of language processing, including the expression and comprehension of speech, reading, writing, and gesture ( Code 2003 ; Parr 1997 ). Variation in the severity of expressive impairments, for example, may range from the individual experiencing occasional word‐finding difficulties to having no effective means of verbal communication. The severity of aphasia can also change over time as one aspect of language difficulty may improve while others remain impaired. The impact and the consequential implications of having aphasia for the individuals themselves, their families, and society highlight the importance of the effective management and rehabilitation of language difficulties caused by aphasia.

Description of the intervention

The primary aim of speech and language therapy (SLT)* in aphasia management and rehabilitation is to maximise individuals' language and communication abilities, activity, and participation. Speech and language therapists are typically responsible for the assessment, diagnosis, and, where appropriate, rehabilitation of aphasia arising as a result of stroke. The ability to successfully communicate a message via spoken, written, or non‐verbal modalities (or a combination of these) within day‐to‐day interactions is known as functional communication. Recent developments have seen speech and language therapists working closely with the person with aphasia, and in partnership with their families and caregivers, to maximise the individual's functional communication and participation.

* For the purposes of clarity within this review we have reserved SLT as an abbreviation for speech and language therapy alone.

Why it is important to do this review

There is no universally accepted treatment that can be applied to every person with aphasia, and typically therapists select from a variety of theoretical approaches, delivery models, and intervention regimens to manage and facilitate rehabilitation. We undertook this 2016 review update to incorporate new evidence and systematic review methodologies and to reflect recent developments in clinical practice. A summary of the differences between the 2016 version and the original 1999 review is presented in Differences between protocol and review .

To assess the effects of speech and language therapy (SLT) for aphasia following stroke. In particular, we aimed to investigate whether:

SLT is more effective than no SLT;
SLT is more effective than social support and stimulation;
one SLT intervention (SLT A) is more effective than another SLT intervention (SLT B).

SLT intervention A or B refers to variations in intervention that differ in duration, intensity, frequency, method, or theoretical basis (e.g. early SLT versus delayed SLT interventions).

Criteria for considering studies for this review

Types of studies.

Randomised controlled trials (RCTs) that evaluated one or more SLT interventions designed to improve language or communication. We included trials that recruited participants with mixed aetiologies or impairments provided it was possible to extract the data specific to individuals with poststroke aphasia. We did not employ any language restriction.

Types of participants

Adults (as defined by the trialists) who had acquired aphasia as a result of a stroke, and families of participating stroke survivors.

Types of interventions

In a change from the 1999 version of the review, all subsequent updates compressed the intervention into three broad groups. We included trials that reported a comparison between a group that received an SLT intervention designed to have an impact on communication and a group that received:

no SLT intervention;
social support and stimulation; or
an alternative SLT intervention.

We considered SLT interventions to be any form of targeted practice tasks or methodologies with the aim of improving language or communication abilities, activities, or participation. These are typically delivered by speech and language therapists. In the UK, 'speech and language therapist' is a protected professional title and refers to individuals holding a professional qualification recognised by the Royal College of Speech and Language Therapists and registered with the Health and Care Professions Council, UK. For the purposes of this review, we extended this definition to include therapists belonging to a body of similar professional standing elsewhere in the world.

We are aware that the SLT profession does not exist in many countries. In trials conducted in such settings, where other clinical staff (e.g. medical or nursing staff) led targeted interventions that aimed to improve participants' communicative functioning, we included these interventions within this review as SLT interventions. We planned a sensitivity analysis of the impact of professional SLT training on the provision of an intervention where data allowed.

We also recognise that current rehabilitation practice may include SLT interventions that aim to improve communicative functioning but are delivered by non‐therapists (family members, SLT assistants, SLT students, voluntary support groups). Where those delivering the intervention received training from a speech and language therapist and delivered an intervention designed by a speech and language therapist, we described these as volunteer‐facilitated SLT interventions.

Social support and stimulation

Social support and stimulation refers to an intervention that provides social support or stimulation but does not include targeted therapeutic interventions that aim to resolve participants' expressive or receptive speech and language impairments. Interventions in this category might include, for example, emotional, psychological, or creative interventions (such as art, dance, or music) as delivered by other healthcare professionals (e.g. art, physical, or music therapists). Other social stimulation interventions, such as conversation or other informal, unstructured communicative interactions, are also included in this category.

We did not include pharmacological interventions for aphasia as they are addressed within a separate review ( Greener 2001 ). We also excluded magnetic or electrical stimulation interventions (e.g. transcranial direct current stimulation (tDCS), transcranial magnetic stimulation, or epidural cortical stimulation) or auditory temporal processing training procedures, as we considered these to be adjuncts to SLT rather than an SLT approach. The effectiveness of tDCS interventions for aphasia is addressed within a separate review ( Elsner 2012 ).

Types of outcome measures

Primary outcomes.

The primary outcome chosen to indicate the effectiveness of an intervention that aims to improve communicative ability must reflect communication activity in real world settings, that is, functional communication. Providing a definition for the concept of functional communication is problematic and makes evaluation difficult. The ability to functionally communicate relates to language or communicational skills sufficient to permit the transmission of a message via spoken, written, or non‐verbal modalities, or through a combination of these channels. Success is typically and naturalistically demonstrated through successful communication of the message ‐ the speaker communicates their message, and the listener understands the message communicated. Attempts to measure this communication success formally vary from analysis of discourse interaction in real life or sampling of discourse during specific tasks (known as discourse analysis). Other more formal tools might include the Communicative Abilities of Daily Living (CADL) or the Communicative Effectiveness Index (CETI) ( Holland 1980 ; Lomas 1989 ).

Secondary outcomes

Given the lack of a comprehensive, reliable, valid, and globally accepted functional communication evaluation tool, surrogate outcome measures of communication impairment (or ability) include formal measures of receptive language (oral, written and gestural), expressive language (oral, written and gestural) or overall level of severity of aphasia where receptive and expressive language are measured using language batteries. Such tools might include, for example, the Western Aphasia Battery (WAB) or the Porch Index of Communicative Abilities (PICA) ( Kertesz 1982 ; Porch 1967 ). Other secondary outcomes of relevance to this review include psychosocial impact (i.e. impact on psychological or social well‐being including mood, depression, anxiety, and distress), satisfaction with intervention, number of dropouts (i.e. the number of participants dropping out at treatment or follow‐up phases for any reason), adherence to allocated intervention (i.e. the number of participants voluntarily withdrawing from their allocated intervention), economic outcomes (such as costs to the patient, caregivers, families, health service, and society) and caregiver and family quality of life. We extracted measures of overall functional status (e.g. Barthel) in the original review as one of a number of primary outcomes. We also extracted these data, where available, as an indicator of overall severity of stroke, but this information is now presented as a patient descriptor within the Characteristics of included studies table. A full list of outcome measures included in the review and their references can be found in Appendix 1 .

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module. We did not impose any language restrictions.

Electronic searches

We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015) ( Appendix 2 ), MEDLINE (1946 to September 2015) ( Appendix 3 ), EMBASE (1980 to September 2015) ( Appendix 4 ), CINAHL (1982 to September 2015) ( Appendix 5 ), AMED (1985 to September 2015) ( Appendix 6 ), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015) using comprehensive search strategies.

We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015) (http://www.clinicaltrials.gov/), the Stroke Trials Registry (to 21 September 2015) (www.strokecenter.org/trials/), Current Controlled Trials (to 22 September 2015) (www.controlled‐trials.com), and WHO ICTRP (http://www.who.int/ictrp/search/en/) (to 22 September 2015).

Searching other resources

We handsearched the International Journal of Language and Communication Disorders (formerly the International Journal of Disorders of Communication , the European Journal of Disorders of Communication , and the British Journal of Disorders of Communication ) from 1969 to December 2005. Since 2006, this journal has been indexed in MEDLINE so our comprehensive electronic search identified any relevant trials published in the journal after that date.
We checked reference lists of all relevant articles to identify other potentially relevant randomised studies.
We contacted all British universities and colleges where speech and language therapists receive training and all relevant Special Interest Groups in the UK to enquire about any relevant published, unpublished, or ongoing studies.
We approached colleagues and authors of relevant randomised trials to identify additional studies of relevance to this review.

Selection of studies

Our selection criteria for inclusion in this review were as follows.

Study participants included people with aphasia as a result of stroke, together with their families.
The SLT intervention was designed to have an impact on communication.
The methodological design was a randomised controlled trial.

One review author (PC) screened titles and abstracts of the records identified through the electronic searches described above and excluded obviously irrelevant studies. We obtained full‐text copies of all the remaining studies that fulfilled the listed inclusion criteria. Two review authors (MB and PC) independently assessed the studies based on the inclusion criteria and decided whether to include or exclude studies. We resolved any disagreements through discussion and involvement of the wider review team. Studies judged ineligible for inclusion, together with reasons for their exclusion, are listed in the Characteristics of excluded studies table.

Data extraction and management

We created and piloted an electronic data extraction tool for use in this 2016 review update. Two review authors (MB and PC) independently confirmed the data for the trials included and extracted the data for the additional trials included in this update. We resolved any disagreements through discussion. We extracted many data elements, including: number and location of sites, methods of randomisation, blinding, attrition from intervention, co‐interventions, confounder details, number of participants, age, education, handedness, sex, native language, severity of aphasia, time post onset, inclusion and exclusion criteria, details of intervention in accordance with the template for intervention description and replication (TIDieR) checklist ( Hoffmann 2014 ), outcome measures and time points used, evidence of an a priori sample size calculation, intention‐to‐treat (ITT) analysis, and summary data. We attempted to contact investigators for any missing data (or data in a suitable format) for inclusion in the review.

Where we identified a cross‐over trial, we based decisions relating to the suitability of the data (either up to or beyond the cross‐over phase) on careful consideration of a range of factors including the intervention(s) used, the timing of the intervention(s), the impact of any treatment carryover, and whether data from relevant paired comparisons within the trial were available. Whenever possible, in such cases we sought individual patient data.

Assessment of risk of bias in included studies

We assessed the trials for methodological quality, paying attention to whether there was protection from the following types of bias: selection bias (i.e. true random sequencing and true concealment up to the time of allocation), performance bias (i.e. differences in co‐interventions between the groups), attrition bias (i.e. withdrawal after trial entry), and detection bias (i.e. 'unmasked' assessment of outcome). We coded concealed allocation as 'low risk', 'unclear' or 'high risk' according to the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ). In addition, we extracted information on whether trialists employed power calculations and ITT analyses. In some cases, for example where all participants were accounted for in the final results, this was not applicable.

Measures of treatment effect

We conducted the review using Review Manager 5 (RevMan) for statistical analysis ( RevMan 2014 ). We recorded descriptive information for each trial (characteristics of participants, interventions, and outcomes) in the Characteristics of included studies table and issues relating to the methodological quality of the trial in the 'Risk of bias' tables. Where trials made a similar comparison and appeared to be sufficiently similar with respect to their descriptive information, we pooled the summary data (where available) using meta‐analysis. We expressed continuous data as differences in means or standardised difference in means and dichotomised data as odds ratios (OR). We used 95% confidence intervals (CI) throughout the review.

The results of the trials in this review reported measures based on differences in final value scores (scores taken at the end of the intervention) and change‐from‐baseline scores (also known as change scores). Although the mean differences (MD) based on change‐from‐baseline scores in randomised trials can generally be assumed to address the same intervention effects as MD analysis based on final value scores, change‐from‐baseline scores are given higher weights in analysis than final value scores ( Higgins 2011 ). For this reason, we have used final value scores within the meta‐analyses wherever possible. We do not report change‐from‐baseline scores unless they were the only available values ( Higgins 2011 ).

Assessment of heterogeneity

We assessed heterogeneity using the I 2 statistic, where any heterogeneity observed may be considered moderate (an I 2 value of 30% to 60%), substantial (50% to 90%) or considerable (75% to 100%) ( Higgins 2011 ). Where we observed important heterogeneity (based of the I 2 value together with significant evidence of heterogeneity as per the Chi 2 test P value), we used a random‐effects model ( Higgins 2011 ).

Data synthesis

Where a single outcome measure was assessed and reported across trials using different measurement tools, we presented these data in a meta‐analysis using a standardised mean difference (SMD) summary statistic. In cases where the direction of measurement differed, it was necessary to adjust the direction of some measures to ensure that all the scales operated in the same direction. For example, measures of comprehension ability generally increase with increasing ability, but in some cases (e.g. the Token Test) improving comprehension skills might be reflected by decreasing scores, so it was necessary to multiply the mean values by −1 to ensure that all the scales operated in the same direction. This method did not affect standard deviation (SD) values, and we have presented these within the meta‐analyses without the need for a directional change.

In cases where trials only reported partial summary data, for example mean final value scores but not SDs (for example Wertz 1981 ), we attempted to calculate these values from available information. When this was not possible, we imputed the SD to facilitate inclusion of the trial within the review by using a SD value from a similar participant group ( Higgins 2011 ). We have reported details of the source of any imputed SD values within the text. Where there was a choice of possible SD values, we imputed the highest and lowest values to ensure that both methods provided a similar overall conclusion and then used the highest value in the presentation of the trial within the forest plot.

Where results in a particular comparison were only available in a mixture of final value and change‐from‐baseline scores, we presented these data graphically using SMDs, but we were unable to pool these results in a meta‐analysis.

Subgroup analysis and investigation of heterogeneity

We did not plan any subgroup analyses.

Sensitivity analysis

The original 1999 review did not include any planned sensitivity analyses. However, we aimed to reflect developments in clinical practice including trials where SLT interventions were delivered or facilitated by non‐speech and language therapists. We planned to conduct sensitivity analyses to evaluate any impact the inclusion of these groups of trials may have had on the results of the review and the impact of trial quality.

Description of studies

The 1999 version of this review included 12 trials, including Kinsey 1986 and Hartman 1987 . Following access to unpublished data from the authors, we excluded quasi‐randomised trials such as Hartman 1987 . We also excluded Kinsey 1986 , which is a comparison of methods of providing therapy materials rather than a comparison of therapy interventions. Thus, of the 12 trials included in the 1999 review, 10 trials remained in the subsequent review updates. We identified an additional 46 trials in the search updates, and we revised the decision to exclude one other trial, Shewan 1984 , from the original review following communication with the trialists, who confirmed that it was an RCT. This updated review is based on data from a total of 57 included trials.

Results of the search

Our search strategy identified 11,314 records from electronic databases. The flow of literature through the searching and screening process is shown in the PRISMA flow diagram ( Figure 1 ). Details of the information requested from the authors of included trials, and whether this was obtained, are given in the Characteristics of included studies table.

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Study flow diagram.

Following our updated search, we identified 18 new trials (23 randomised comparisons) for inclusion in this 2016 review update ( B.A.Bar 2011i ; B.A.Bar 2011ii ; CACTUS 2013 ; Conklyn 2012 ; Crosson 2014 ; FUATAC ; Mattioli 2014 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; SEMaFORE ; Sickert 2014 ; SP‐I‐RiT ; Szaflarski 2014 ; Varley 2016i ; Varley 2016ii ; VERSE II ; Wilssens 2015 ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ; Wu 2013 ; Xie 2002 ). In addition we identified 18 ongoing studies ( TNT ‐ ACTRN12614000081617 ; ASK ; Big CACTUS ; CATChES ; COMPARE ; Nehra ‐ CTRI/2014/04/004554 ; FCET2EC ; IMITATE ; Kukkonen 2007 ; LIFT 2014 ; MIT USA ; Kurland ‐ {"type":"clinical-trial","attrs":{"text":"NCT02012374","term_id":"NCT02012374"}} NCT02012374 ; ORLA‐Write ; Osborne 2012 ; PMvSFA ; RATS‐3 ; U‐Health ; VERSE III ); these are likely to be eligible for inclusion in the review at a later date. These studies are detailed in the Characteristics of ongoing studies table.

Included studies

We included a total of 57 trials involving 3002 participants in this review. Several trials contributed to more than one comparison and so numbers of participants contributing to each comparison should be considered separately (SLT versus no SLT N = 1620; SLT versus social support and stimulation N = 447; SLT A versus SLT B N = 1242) and cannot be summed across comparisons.

Ten trials randomised individuals across three or more groups (trial arms) but for the purposes of this review and the meta‐analyses we have presented and pooled the data within randomised paired comparisons indicated as i, ii or iii. For example, data from Yao 2005 are presented across three 'trials' of SLT versus no SLT ( Yao 2005i ), individual SLT versus no SLT ( Yao 2005ii ) and SLT versus individual SLT ( Yao 2005iii ). Other trials affected were B.A.Bar 2011i, B.A.Bar 2011ii, Katz 1997i, Katz 1997ii, Lincoln 1982i, Lincoln 1982ii, Lincoln 1982iii, MIT 2014i, MIT 2014ii, Shewan 1984i, Shewan 1984ii, Shewan 1984iii, Smith 1981i, Smith 1981ii, Smith 1981iii, Varley 2016i, Varley 2016ii, Wertz 1986i, Wertz 1986ii, Wertz 1986iii, Woolf 2015i, Woolf 2015ii, Woolf 2015iii, Zhang 2007i, and Zhang 2007ii . In other cases where a single research group published different trials within the same year; these are indicated as for example Lincoln 1984a , and Lincoln 1984b . Further details can be found in the Characteristics of included studies . In the 'duplicate' trials, there was a risk of including the same group of participants (usually the control group) twice in a single meta‐analysis, so we split the number of participants in the control group across the two 'trials' that shared that comparison group ( Higgins 2011 ). In the case of continuous data, the mean and SD values remained the same. In the case of dichotomous data, we split both the number of events and total number of patients across the relevant number of arms. In keeping with previous reviews where this method has been used and for ease of reading, these paired randomised comparisons will be referred to as trials from this point onwards.

Thirteen trials employed a cross‐over design ( B.A.Bar 2011i ; B.A.Bar 2011ii ; Crerar 1996 ; Elman 1999 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1982iii ; Lincoln 1984b ; Varley 2016i ; Varley 2016ii ; Wertz 1986i ; Wertz 1986ii ; Wertz 1986iii ). We carefully considered the suitability of each cross‐over trial for inclusion within the review. We considered factors including the suitability of the design, the intervention(s) used, the timing of the intervention(s), the impact of any treatment carry‐over and finally whether data from relevant paired comparisons from the cross‐over data were available. For eight trials we extracted data up to the point of cross‐over ( B.A.Bar 2011i ; Crerar 1996 ; Elman 1999 ; Lincoln 1982iii ; Lincoln 1984b ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ). In some cases though, the treatment that participants were allocated to receive following cross‐over was 'no SLT' or similar. In these cases, the 'no SLT' input after cross‐over could be used as a follow‐up period or deferred delivery of therapy (e.g. B.A.Bar 2011ii ; Varley 2016ii ).

In contrast, Lincoln 1982 was also a cross‐over trial in design, with participants randomly allocated to one of four groups with a sequence of interventions that included one active treatment or placebo, either preceded by or followed by conventional SLT. We were able to access the unpublished individual patient trial data for this review. This access to the data, the design, nature and manner of SLT delivery within the trial and the clinical relevance of the comparisons made it possible to include two paired comparisons of those groups within the review.

SLT + operant training versus SLT + social support ( Lincoln 1982i ).
Operant training + SLT versus social support + SLT ( Lincoln 1982ii ).

Taking the individual data at the point of measurement prior to the cross‐over, it was also possible to extract and compare the data from those that had received conventional SLT and compare it to those participants that received a social support and stimulation intervention ( Lincoln 1982iii ).

We present data from 73 randomised comparisons as they relate to the effectiveness of SLT for aphasia following stroke, which compare: SLT versus no SLT, SLT versus social support and stimulation, and SLT A versus SLT B. We have presented details of data within each comparison below with further details on each trial available in the Characteristics of included studies table. Details of participants (age, sex, time since stroke, and aphasia severity by trial ( Table 6 )), SLT interventions ( Appendix 7 ), and assessment tools ( Appendix 1 ) by randomised group are also available. A summary of the findings is available at the end of the Results section ( Table 1 ; Table 2 ; Table 3 ; Table 4 ; Table 5 ).

Summary of findings for the main comparison

a Downgraded 1 level from high to moderate as there were serious limitations identified in the risk of bias (either unclear randomisation sequence, unclear or high risk of bias for allocation concealment, or both in 1 or more of the trials). b See notes about dropouts. c Downgraded 1 level of evidence as wide confidence intervals identified.

Summary of findings 2

a Serious limitations identified in the risk of bias. b Low number of studies/participants. c See notes about dropouts.

Summary of findings 3

Summary of findings 4.

a See notes about dropouts. b Low number of studies/participants. c Serious limitations identified in the risk of bias in 1 or more of the included trials.

Summary of findings 5

a See notes about dropouts. b Low number of studies/participants. c Serious limitations identified in the risk of bias in one or more of the included trials.

AAT : Aachen Aphasia Test; ABC : Aphasia Battery of Chinese; ANELT : Amsterdam‐Nijmegen Everyday Language Test; AQ : Aphasia Quotient; BDAE : Boston Diagnostic Aphasia Examination; BNT : Boston Naming Test; CAT : Comprehensive Aphasia Test; CIAT : Constraint Induced Aphasia Therapy; FCP : Functional Communication Profile; FE scale: Functional‐Expression scale; IQR : interquartile range; MIT : Melodic Intonation Therapy; M‐S Comprehension Test : Morpho‐Syntactic Comprehension Test; MTDDA : Minnesota Test for the Differential Diagnosis of Aphasia; NIHSS : National Institutes of Health Stroke Scale; PICA : Porch Index of Communicative Abilities; SD : standard deviation; SLT : Speech and Language therapy/therapist; SPICA : Shortened Porch Index of Communicative Abilities; STACDAP : Systematic Therapy for Auditory Comprehension Disorders in Aphasic Patients; TOMs : Therapy Outcome Measures; WAB : Western Aphasia Battery; WABAQ : Western Aphasia Battery Aphasia Quotient.

1. SLT versus no SLT

We included 27 randomised comparisons involving 1620 randomised participants in this section ( B.A.Bar 2011i ; CACTUS 2013 ; Conklyn 2012 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Lincoln 1984a ; Liu 2006a ; Lyon 1997 ; MacKay 1988 ; Mattioli 2014 ; Smania 2006 ; Smith 1981i ; Smith 1981ii ; Szaflarski 2014 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Wu 2004 ; Wu 2013 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). The SLT intervention was typically delivered by a speech and language therapist. In three trials, a therapist‐trained volunteer facilitated therapy ( CACTUS 2013 ; MacKay 1988 ; Wertz 1986ii ), but some trials were based on independent practice with SLT support ( B.A.Bar 2011i ; Szaflarski 2014 ; Varley 2016i ). Alternative models of intervention delivery included administration by a doctor or nurse ( Wu 2004 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Zhao 2000 ), a music therapist ( Conklyn 2012 ), or other therapists in the rehabilitation setting ( Zhang 2007i ; Zhang 2007ii ). In two trials, it was unclear who facilitated the SLT intervention ( Liu 2006a ; Wu 2013 ). Two additional trials compared groups that did and did not receive SLT, but the participants were not randomly assigned to these 'no SLT' groups, so we excluded them from this review ( Prins 1989 ; Shewan 1984 ).

The trials in this section employed a range of SLT interventions that might be broadly grouped as conventional SLT ( Lincoln 1984a ; Liu 2006a ; Mattioli 2014 ; Smania 2006 ; Smith 1981ii ; Wertz 1986i ; Wu 2004 ; Wu 2013 ; Xie 2002 ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ), constraint‐induced aphasia therapy ( Szaflarski 2014 ), melodic intonation therapy ( Conklyn 2012 ), intensive SLT ( B.A.Bar 2011i ; Laska 2011 ; Szaflarski 2014 ; Smith 1981i ; Xie 2002 ), group SLT ( Yao 2005i ), volunteer‐facilitated ( MacKay 1988 ; Wertz 1986ii ), computer‐mediated SLT ( B.A.Bar 2011i ; CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Varley 2016i ), and functionally‐based SLT involving a communicative partner ( Lyon 1997 ). An acupuncture co‐intervention was delivered alongside the SLT intervention in three comparisons ( Liu 2006a ; Zhao 2000 ; Zhang 2007ii ).

Most participants randomised to the 'no SLT' groups received no alternative treatment or support ( Doesborgh 2004 ; Katz 1997i ; Laska 2011 ; Lincoln 1984a ; Liu 2006a ; Lyon 1997 ; MacKay 1988 ; Wertz 1986i ; Wertz 1986ii ; Wu 2004 ; Yao 2005i ; Yao 2005ii ). Only seven trials described an intervention within these 'no SLT' groups. In CACTUS 2013 , we considered the control interventions to be similar to standard poststroke care in the local region at that time; in Smith 1981i and Smith 1981ii , a health visitor went to participants' homes; in Smania 2006 , participants received limb apraxia therapy; and in Zhang 2007i , Zhang 2007ii , and Zhao 2000 , they received medication. The control groups in Katz 1997ii received computer‐based cognitive tasks ('arcade‐style games') and in B.A.Bar 2011i and Varley 2016i , they received visual‐cognitive computer games, all interventions designed not to target language rehabilitation.

The timing of SLT interventions after the onset of aphasia varied widely and is difficult to summarise because of a lack of detailed reporting. Some trialists recruited participants within two to four days after the onset of stroke ( Laska 2011 ; Mattioli 2014 ), while others recruited participants up to 45 days ( Liu 2006a ), 10 weeks ( Lincoln 1984a ), three months ( Conklyn 2012 ; Wu 2013 ; Zhang 2007i ; Zhang 2007ii ) or six months ( Wertz 1986i ; Wertz 1986ii ) after the stroke. Other trials recruited participants longer after stroke, for example between two months and three years after stroke ( Smania 2006 ), or for up to four years ( B.A.Bar 2011i ). Other participants were recruited one year or more after their stroke ‐ up to 17 months in Doesborgh 2004 , two years in MacKay 1988 , eight years in Varley 2016i , 10 years in Lyon 1997 , 19 years in Katz 1997i , 22 years in Katz 1997ii , and 29 years in CACTUS 2013 (see Table 6 for details). Eight trials failed to report the timing of the SLT intervention in relation to the onset of participants' aphasia ( Smith 1981i ; Smith 1981ii ; Szaflarski 2014 ; Wu 2004 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Zhao 2000 ).

The frequency of SLT was reported as the number of times daily or as hours per day or per week. Participants received daily SLT (duration unclear) in two trials ( Yao 2005i ; Yao 2005ii ), weekly SLT for up to an hour ( CACTUS 2013 ; Conklyn 2012 ), two hours ( Doesborgh 2004 ; Lincoln 1984a ; Smith 1981ii ), three hours ( Katz 1997i ; Katz 1997ii ; Smania 2006 ; Wu 2013 ), four hours ( Laska 2011 ; Smith 1981i ), five hours ( Mattioli 2014 ; Varley 2016i ), six hours ( MacKay 1988 ; Xie 2002 ), eight hours ( Lyon 1997 ), nine hours ( B.A.Bar 2011i ), or 10 hours ( Wertz 1986i ; Wertz 1986ii ). An additional six comparisons did not report the frequency of the SLT intervention ( Liu 2006a ; Szaflarski 2014 ; Wu 2004 ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). Where specified, the duration of the SLT intervention varied from one session ( Conklyn 2012 ), two weeks ( Mattioli 2014 ), three weeks ( Laska 2011 ), four weeks ( B.A.Bar 2011i ), six weeks ( Varley 2016i ), two months ( Zhao 2000 ), up to three months ( Doesborgh 2004 ; Smania 2006 ; Wertz 1986i ; Wertz 1986ii ; Yao 2005i ; Yao 2005ii ); between five and six months ( CACTUS 2013 ; Katz 1997i ; Katz 1997ii ; Lincoln 1984a ; Lyon 1997 ; Wu 2004 ), or for up to one year ( MacKay 1988 ; Smith 1981i ; Smith 1981ii ; Xie 2002 ).

The 19 randomised comparisons in this section used a wide range of outcome measures including functional communication, receptive language, expressive language, severity of impairment, psychosocial impact and economic outcomes. One of the 14 trials did not report any outcome measures ( Wu 2004 ). Eleven trials carried out follow‐up assessments after SLT at 2 months ( Smania 2006 ), 3 months ( B.A.Bar 2011i ; Szaflarski 2014 ; Wertz 1986i ; Wertz 1986ii ; Yao 2005i ; Yao 2005ii ), 5 months ( CACTUS 2013 ), 6 months ( Laska 2011 ; MacKay 1988 ; Mattioli 2014 ), 8 months ( CACTUS 2013 ), and 12 months ( MacKay 1988 ).

2. SLT versus social support and stimulation

We included nine trials with 447 randomised participants in this section ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Lincoln 1982iii ; Rochon 2005 ; Shewan 1984ii ; Shewan 1984iii ; Woolf 2015ii ; Woolf 2015iii ). They reported a range of SLT approaches, including conventional SLT ( ACTNoW 2011 ; David 1982 ; Lincoln 1982iii ; Shewan 1984iii ; Woolf 2015iii ), group SLT ( Elman 1999 ), telerehabilitation SLT ( Woolf 2015ii ), language‐oriented SLT ( Shewan 1984ii ), and sentence mapping SLT ( Rochon 2005 ). The social support and stimulation interventions were provided by paid visitors not previously known to the participants with aphasia ( ACTNoW 2011 ; David 1982 ), nursing staff ( Shewan 1984ii ; Shewan 1984iii ), speech and language therapists or speech and language therapy students ( Lincoln 1982iii ; Woolf 2015ii ; Woolf 2015iii ), a trained research assistant ( Rochon 2005 ), or through other social group activities including movement classes, creative arts groups, church activities or support groups ( Elman 1999 ). All visitors providing the ACTNoW 2011 social support received training and a manual of non‐therapeutic activities, suitable conversation topics, and access to equipment. David 1982 provided its volunteers with detailed information on their patients' communication problems, and they received instructions to "encourage their patient to communicate as well as possible". Similarly, the nursing staff volunteers received some information about aphasia and instructions to "stimulate communication to the best of their ability" ( Shewan 1984ii ; Shewan 1984iii ). The volunteers did not receive guidance or instruction in SLT techniques in any of the four trials. Speech and language therapy students received a training session in supported conversation approaches (e.g. initiation and adaptation of communication) and a handbook ( Woolf 2015ii ; Woolf 2015iii ).

The duration of participants' aphasia varied between trials and was reported as: an average of 12 days ( ACTNoW 2011 ), an average of between 3 and 5 years ( Woolf 2015ii ; Woolf 2015iii ), up to 4 weeks ( Shewan 1984ii ; Shewan 1984iii ), up to 3 years ( David 1982 ; Lincoln 1982iii ), 7 months to 28 years ( Elman 1999 ), or between 2 and 9 years ( Rochon 2005 ). Interventions were provided weekly for up to two hours ( David 1982 ; Lincoln 1982iii ; Woolf 2015ii ; Woolf 2015iii ), three hours ( ACTNoW 2011 ; Shewan 1984ii ; Shewan 1984iii ), or five hours ( Elman 1999 ); or over the course 1 month ( Lincoln 1982iii ; Woolf 2015ii ; Woolf 2015iii ), 4 months ( ACTNoW 2011 ; Elman 1999 ), 5 months ( David 1982 ), or 12 months ( Shewan 1984ii ; Shewan 1984iii ).

Outcome measures used in this comparison included measures of functional communication, receptive language, expressive language and levels of severity of impairment. Five trials carried out follow‐up measures at four weeks ( Rochon 2005 ), three months ( David 1982 ; Woolf 2015ii ; Woolf 2015iii ), and six months ( David 1982 ).

3. SLT A versus SLT B

We included 38 trials involving 1242 randomised participants in this section ( B.A.Bar 2011ii ; Bakheit 2007 ; Crerar 1996 ; Crosson 2014 ; Denes 1996 ; Di Carlo 1980 ; Drummond 1981 ; FUATAC ; Hinckley 2001 ; Leal 1993 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1984b ; Meikle 1979 ; Meinzer 2007 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; ORLA 2006 ; ORLA 2010 ; Prins 1989 ; Pulvermuller 2001 ; RATS ; RATS‐2 ; SEMaFORE ; Shewan 1984i ; Sickert 2014 ; Smith 1981iii ; SP‐I‐RiT ; Van Steenbrugge 1981 ; Varley 2016ii ; VERSE I ; VERSE II ; Wertz 1981 ; Wertz 1986iii ; Wilssens 2015 ; Woolf 2015i ; Yao 2005iii ). Four trials also reported additional groups, but these participants were not adequately randomised to the groups, so we excluded them from this review ( Bakheit 2007 ; ORLA 2006 ; Prins 1989 ; Shewan 1984 ).

Studies reported a wide range of SLT interventions, including variations in therapy regimen such as therapy intensity ( Bakheit 2007 ; Denes 1996 ; FUATAC ; ORLA 2006 ; Smith 1981iii ; SP‐I‐RiT ; VERSE I ), duration of therapy ( Di Carlo 1980 ; Meikle 1979 ; ORLA 2010 ; Pulvermuller 2001 ; SP‐I‐RiT ), or delayed delivery ( B.A.Bar 2011ii ; MIT 2014i ; Lyon 1997 ; Varley 2016ii ). Other comparisons included variation in the delivery approach, such as volunteer‐facilitated SLT ( Meikle 1979 ; Meinzer 2007 ; Leal 1993 ; Wertz 1986iii ), computer‐facilitated SLT ( ORLA 2010 ), and group SLT ( FUATAC ; Pulvermuller 2001 ; Wertz 1981 ; Yao 2005iii ). Variations in the theoretical approach included constraint‐induced aphasia therapy ( FUATAC ; Pulvermuller 2001 ; Sickert 2014 ; VERSE II ; Wilssens 2015 ), semantic therapy ( RATS ; RATS‐2 ; SEMaFORE ; Wilssens 2015 ), phonological approaches ( Wilssens 2015 ) or melodic intonation therapy ( MIT 2014i ; MIT 2014ii ). Other trials compared verb versus preposition therapies ( Crerar 1996 ), filmed programmed instructions versus non‐programmed activity ( Di Carlo 1980 ), or programmed instruction versus a placebo ( Lincoln 1984b ).

The average time since onset of participants' aphasia varied from less than a week ( VERSE I ; VERSE II ), up to 1 month ( Bakheit 2007 , Leal 1993 ; RATS‐2 ; Shewan 1984i ; Sickert 2014 ; Wertz 1981 ), 2 months ( SP‐I‐RiT ; Varley 2016ii ; Wertz 1986iii ), 3 months ( Denes 1996 ; MIT 2014i ; MIT 2014ii ), 4 months ( RATS ), 5 months ( Lincoln 1982i ), 6 months ( Lincoln 1984b ), 9 months ( Lincoln 1982ii , Meikle 1979 ), 10 months to one year ( Prins 1989 ), two years ( Di Carlo 1980 , Drummond 1981 ; Hinckley 2001 ; Van Steenbrugge 1981 ), three years ( B.A.Bar 2011ii ; Crosson 2014 ; Meinzer 2007 ; Woolf 2015i ), four years ( NARNIA 2013 ; ORLA 2006 ), five years ( Wilssens 2015 ), six years ( ORLA 2010 ), seven years ( Crerar 1996 ), or eight years ( Pulvermuller 2001 ). The duration of participants' aphasia was unavailable for other trials ( FUATAC ; SEMaFORE ; Smith 1981iii ; Yao 2005iii ).

Participants received therapy daily for an unclear time period ( Yao 2005iii ), for up to two hours ( Crerar 1996 ; SP‐I‐RiT ), or for three hours ( Meinzer 2007 ; Pulvermuller 2001 ). Participants receiving SLT weekly had cumulative sessions for up to 30 minutes ( Drummond 1981 ), 45 minutes ( FUATAC ), 1 hour ( Lincoln 1984b ), 1.5 hours ( Lincoln 1982i ; Smith 1981iii ), 2 hours ( Prins 1989 ; SEMaFORE ; Van Steenbrugge 1981 ; Woolf 2015i ), 3 hours ( Di Carlo 1980 ; FUATAC ; RATS ; Leal 1993 ; Shewan 1984i ), 4 hours ( Meikle 1979 ; NARNIA 2013 ; Smith 1981iii ), 5 hours ( Bakheit 2007 ; Denes 1996 ; MIT 2014i ; MIT 2014ii ; RATS‐2 ; SP‐I‐RiT ; VERSE II ), 6 hours ( Varley 2016ii ), 7 hours ( VERSE I ), 8 hours ( Wertz 1981 ), 9 hours ( B.A.Bar 2011ii ), 10 hours ( Crosson 2014 ; ORLA 2006 ; Wertz 1986iii ), 15 hours ( Wilssens 2015 ), or 20 hours ( Hinckley 2001 ). The duration of therapy ranged from 2 weeks ( Drummond 1981 ; Meinzer 2007 ; Wilssens 2015 ), 3 weeks ( Crerar 1996 ; Crosson 2014 ; SP‐I‐RiT ), 4 weeks ( Lincoln 1984b ; VERSE I ; Woolf 2015i ; Yao 2005iii ), 5 weeks ( Hinckley 2001 ; NARNIA 2013 ; Pulvermuller 2001 ; VERSE II ), 6 weeks ( FUATAC ; MIT 2014i ; ORLA 2006 ; SEMaFORE ; Varley 2016ii ), 8 weeks ( B.A.Bar 2011ii ; Lincoln 1982i ; Lincoln 1982ii ), 9 weeks ( Van Steenbrugge 1981 ), 10 weeks ( SP‐I‐RiT ), 12 weeks ( Bakheit 2007 ; MIT 2014ii ; Wertz 1986iii ), 30 weeks ( Di Carlo 1980 ), 5 months ( Prins 1989 ), up to 6 months ( Denes 1996 ; Leal 1993 ; RATS‐2 ), 9 months ( RATS ), 10 months ( Wertz 1981 ), one year ( Shewan 1984i ; Smith 1981iii ), or two years ( Meikle 1979 ). The self directed therapy intervention varied across participants in ORLA 2010 , with each participant receiving 24 hours of therapy over a mean treatment duration of 12.62 weeks (range 6 to 22 weeks), and in Varley 2016ii (means reported above).

There was a wide range of outcome measures used in this comparison, including measures of functional communication, receptive language, expressive language, severity of impairment, and psychosocial impact. Investigators carried out post‐treatment follow‐up assessments at five weeks ( NARNIA 2013 ), six weeks ( Wertz 1986iii ), eight weeks ( Sickert 2014 ; Varley 2016ii ), nine weeks ( Van Steenbrugge 1981 ), three months ( B.A.Bar 2011ii ; Bakheit 2007 ; Crosson 2014 ; SP‐I‐RiT ; VERSE II ; Wertz 1986iii ; Woolf 2015i ; Yao 2005iii ), six months ( VERSE I , VERSE II ), and 12 months ( Sickert 2014 ) .

Excluded studies

We excluded 65 studies. Reasons for exclusion were primarily due to inadequate randomisation and the unavailability of aphasia‐specific data (see details in the Characteristics of excluded studies table).

Risk of bias in included studies

Two review authors independently reviewed the methodological quality of the included studies and resolved disagreements through discussion. We present details in the 'Risk of bias' tables for each of the trials in the Characteristics of included studies table.

The number of randomised participants in included studies ranged from five participants in Rochon 2005 and Wu 2013 to 327 participants in Lincoln 1984a . Nine comparisons randomised 10 participants or fewer ( Crerar 1996 ; Drummond 1981 ; Rochon 2005 ; Van Steenbrugge 1981 ; Wilssens 2015 ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ; Wu 2013 ), 17 randomised between 11 and 20 participants ( B.A.Bar 2011i ; B.A.Bar 2011ii ; Crosson 2014 ; Denes 1996 ; Di Carlo 1980 ; Doesborgh 2004 ; Hinckley 2001 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1982iii ; Lincoln 1984b ; Mattioli 2014 ; Meinzer 2007 ; NARNIA 2013 ; ORLA 2006 ; Pulvermuller 2001 ; VERSE II ), 26 trials randomised up to 50 participants ( CACTUS 2013 ; Conklyn 2012 ; Elman 1999 ; FUATAC ; Katz 1997i ; Katz 1997ii ; Liu 2006a ; Lyon 1997 ; Meikle 1979 ; MIT 2014i ; MIT 2014ii ; ORLA 2010 ; Prins 1989 ; SEMaFORE ; Shewan 1984iii ; Smania 2006 ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; SP‐I‐RiT ; Szaflarski 2014 ; Varley 2016i ; Varley 2016ii ; Xie 2002 ; Zhang 2007i ; Zhang 2007ii ), 16 trials randomised between 51 and 100 participants ( Bakheit 2007 ; Leal 1993 ; MacKay 1988 ; RATS ; RATS‐2 ; Shewan 1984i ; Shewan 1984ii ; Sickert 2014 ; VERSE I ; Wertz 1981 ; Wertz 1986i ; Wertz 1986ii ; Wertz 1986iii ; Yao 2005i ; Yao 2005ii ; Yao 2005iii ), 2 trials randomised between 101 and 150 ( Laska 2011 ; Zhao 2000 ), and 4 randomised more than 150 participants ( ACTNoW 2011 ; David 1982 ; Lincoln 1984a ; Wu 2004 ) (see Table 6 ).

Of the 74 randomised comparisons, only 44 listed both inclusion and exclusion criteria. Details of exclusion criteria were unavailable for an additional 28 trials ( B.A.Bar 2011i ; B.A.Bar 2011ii ; Crerar 1996 ; Denes 1996 ; Di Carlo 1980 ; Hinckley 2001 ; Lincoln 1984b ; Lyon 1997 ; MacKay 1988 ; Meikle 1979 ; Meinzer 2007 ; ORLA 2006 ; Prins 1989 ; Rochon 2005 ; Szaflarski 2014 ; Van Steenbrugge 1981 ; Wertz 1981 ; Wertz 1986i ; Wertz 1986ii ; Wertz 1986iii ; Wu 2013 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Yao 2005iii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). Inclusion and exclusion criteria were unavailable for two trials ( Drummond 1981 ; Wu 2004 ) (see Characteristics of included studies table).

Suitable statistical data for communication outcomes were only available for 55 of the 74 trials. Appropriate statistical data for communication outcomes were not provided or could not be extracted in the remaining 18 randomised comparisons ( Conklyn 2012 ; Drummond 1981 ; Elman 1999 ; FUATAC ; Leal 1993 ; Lyon 1997 ; MacKay 1988 ; MIT 2014ii ; SEMaFORE ; Shewan 1984i ; Shewan 1984ii ; Shewan 1984iii ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; Szaflarski 2014 ; Wu 2004 ; Wu 2013 ). Nine of these trials contributed data on the trial dropouts or withdrawals ( Elman 1999 ; Leal 1993 ; MacKay 1988 ; Shewan 1984i ; Shewan 1984ii ; Shewan 1984iii ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ).The nine remaining trials did not contribute any data to the review meta‐analyses ( Conklyn 2012 ; Drummond 1981 ; FUATAC ; Lyon 1997 ; MIT 2014ii ; SEMaFORE ; Szaflarski 2014 ; Wu 2004 ; Wu 2013 ). Psychosocial data were available for three trials ( ACTNoW 2011 ; Lincoln 1984a ; SP‐I‐RiT ).

There was a wide range of variation in the descriptions of the SLT interventions. Most reported the use of a conventional SLT approach or described an intervention, which reflects clinical practice where the therapist was responsible for design and content of the treatment delivered. Other trials evaluated more prescriptive SLT interventions (including volunteer‐facilitated therapy, intensive therapy, constraint‐induced asphasia therapy for example); we will describe these in later sections. We systematically extracted intervention details according to the Template for Intervention Description and Replication (TIDieR) checklist ( Hoffmann 2014 ), communicating directly with the trialists to supplement published information where possible. We present these intervention detail in the Characteristics of included studies table.

Forty‐nine randomised comparisons reported similar groups at baseline. Comparison between the groups at baseline was unclear in 10 randomised comparisons ( FUATAC ; Lincoln 1984b ; Lyon 1997 ; MacKay 1988 ; SEMaFORE ; Wu 2004 ; Wu 2013 ; Yao 2005i ; Yao 2005ii ; Yao 2005iii ). For 15 randomised comparisons, the groups differed despite randomisation in relation to their time post onset ( Pulvermuller 2001 ), the severity or type of their stroke ( VERSE I ; VERSE II ), severity of their aphasia ( Smith 1981i ; Smith 1981ii ), sex ( Crerar 1996 ; MIT 2014i ; MIT 2014ii ; RATS‐2 ; Varley 2016ii ), and age ( David 1982 ; RATS ; Meinzer 2007 ; Prins 1989 ); in Meikle 1979 the participants that were allocated to SLT received more weeks of the intervention than the volunteer‐facilitated group (P = 0.01).

Details of the method of generating the randomisation sequence were only available for 32 of the 74 trials (see Figure 2 ; Figure 3 ). Twelve used random numbers tables ( Bakheit 2007 ; Conklyn 2012 ; David 1982 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1982iii ; Lincoln 1984a ; Lincoln 1984b ; Smania 2006 ), 20 used computer‐generated or web‐based sequence generation ( ACTNoW 2011 ; CACTUS 2013 ; Doesborgh 2004 ; Mattioli 2014 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; Varley 2016i ; Varley 2016i i; Pulvermuller 2001 ; RATS ; RATS‐2 ; SP‐I‐RiT ; Sickert 2014 ; VERSE I ; VERSE II ; Wilssens 2015 ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ), and one drew lots ( Crerar 1996 ). The remaining 42 trials stated that participants were randomly allocated but did not report any further details. Eight trials described stratifying participants by type or severity of aphasia ( ACTNoW 2011 ; CACTUS 2013 ; Crosson 2014 ; Leal 1993 ; Shewan 1984i ; Shewan 1984ii ; Shewan 1984iii ; SP‐I‐RiT ), and two stratified by recruitment site ( ACTNoW 2011 ; RATS‐2 ).

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'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.

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'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.

Details of the allocation concealment were available for 31 of the 74 trials (see Figure 2 and Figure 3 ). Nineteen used sequentially numbered sealed envelopes or similar methods of allocation and were considered to be adequately concealed ( Bakheit 2007 ; CACTUS 2013 ; Conklyn 2012 ; David 1982 ; Doesborgh 2004 ; Lincoln 1984a ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; RATS ; SP‐I‐RiT ; Sickert 2014 ; Varley 2016i ; Varley 2016i i; VERSE II ; Wilssens 2015 ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ). Five described using an allocation service that was external to the trial team ( ACTNoW 2011 ; Laska 2011 ; RATS‐2 ; SEMaFORE ; VERSE I ). Seven described a trialist‐led allocation method that inadequately concealed allocation to the groups ( Crerar 1996 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1982iii ; Lincoln 1984b ; Mattioli 2014 ; Smania 2006 ).

Due to the nature of SLT, it is difficult to blind either the patient or the person carrying out the intervention. However, blinding of the outcome assessor is possible and should be in place to avert detection bias. More than half of the included trials (43/74) reported blinding of outcome assessors (see Figure 2 and Figure 3 ). In other cases, blinding was partially in place. The method of assessment ensured blinding in some of the outcome measures for three trials ( Crerar 1996 ; Lincoln 1984b ; RATS‐2 ), while six additional trials ensured blinding of a second assessor who checked a proportion of measurements scores ( Katz 1997i ; Katz 1997ii ; Rochon 2005 ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ). Four trial reports acknowledged the possibility that measures may have been confounded to some extent by indications from the participants being assessed as to which group they were attending ( ACTNoW 2011 ; David 1982 ; MIT 2014i ; MIT 2014ii ). This is likely to have occurred but went unreported in several other trials as well.

Blinding was unclear for 20 trials ( Crosson 2014 ; Di Carlo 1980 ; Drummond 1981 ; FUATAC ; Hinckley 2001 ; Lincoln 1984b ; Liu 2006a ; MIT 2014i ; MIT 2014ii ; ORLA 2006 ; ORLA 2010 ; Prins 1989 ; RATS‐2 ; Shewan 1984i ; Shewan 1984ii ; Shewan 1984iii ; Van Steenbrugge 1981 ; Wilssens 2015 ; Wu 2013 ; Zhao 2000 ), and we considered it inadequate in 11 trials ( Doesborgh 2004 ; Elman 1999 ; Lyon 1997 ; Meikle 1979 ; Rochon 2005 ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; Woolf 2015i ; Woolf 2015ii ; Woolf 2015iii ).

Incomplete outcome data

Overall, 25% of the 3002 participants randomised across the 74 comparisons included in this review withdrew from the intervention (N = 518 participants) or were lost to follow‐up (N = 254 participants). By specific comparisons, of the 1620 participants in the SLT versus no SLT comparison, 235 (15%) withdrew from the treatment phase of the studies: 116 from the SLT interventions and 117 from the 'no SLT' allocation. In addition, 46 participants were lost during the follow‐up assessment phase (21 withdrawing from the SLT groups and 25 from the 'no SLT' groups). The trials that compared SLT with social support and stimulation randomised a total of 447 participants, but 105 participants (23%) were lost during the treatment phase (40 from the SLT group and 65 from the social support groups). Twenty‐five additional participants were not included in the follow‐up ( David 1982 ; Elman 1999 ). The final comparison of SLT A versus SLT B involved 1242 randomised participants. A total of 224 participants (18%) withdrew from these trials during the treatment phase, with an additional 90 withdrawing from the follow‐up phase. Across the review, studies reported an additional five participants withdrawing from a trial, but it was unclear to which group(s) those participants were allocated ( Smith 1981i ; Smith 1981ii ; Smith 1981iii ). Participants in Meikle 1979 remained in the trial until two successful estimations on an outcome measure showed no appreciable improvement, until participants requested withdrawal, or until the end of the trial; however, authors gave no further details. Where available, we present details of dropouts in Table 7 .

ANELT : Amsterdam‐Nijmegen Everyday Language Test; SLT : speech and language therapy.

Selective reporting

Recruitment and retention of stroke rehabilitation trial participants is known to be a challenge, and the trials in this review were no exception. However, seven trials only reported data (including demographic data) from participants that remained in the trial at the end of treatment or at follow‐up. David 1982 reported data from 133 of 155 randomised participants, Doesborgh 2004 reported 18 of 19 randomised participants, Katz 1997i reported 36 of 42 randomised participants, Katz 1997ii reported 40 of 42 randomised participants, Lincoln 1984a reported 191 of 327 randomised participants, MacKay 1988 reported 95 of 96 randomised participants, and Smania 2006 reported 33 of 41 randomised participants.

We considered most included studies (54/74) to be at low risk of reporting bias (see Figure 2 and Figure 3 ). We judged 11 studies as having an unclear risk of reporting bias ( Conklyn 2012 ; Drummond 1981 ; Elman 1999 ; Leal 1993 ; SEMaFORE ; Smania 2006 ; Szaflarski 2014 ; Wertz 1981 ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ), and we considered eight trials to be at high risk of reporting bias ( FUATAC ; MacKay 1988 ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; Wu 2004 ; Wu 2013 ; Xie 2002 ). We provide details of the reporting bias in the Characteristics of included studies .

Twelve trials reported using ITT analysis ( ACTNoW 2011 ; Bakheit 2007 ; CACTUS 2013 ; Laska 2011 ; MIT 2014i ; MIT 2014ii ; RATS ; RATS‐2 ; SP‐I‐RiT ; Varley 2016i ; Varley 2016ii , VERSE I ). Not all participants appeared to be included in the final analyses within two trials ( Bakheit 2007 ; RATS ). In addition, 28 trials that reported participants that had dropped out did not report using ITT analysis ( David 1982 ; Doesborgh 2004 ; Elman 1999 ; Katz 1997i ; Katz 1997ii ; Leal 1993 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1982iii ; Lincoln 1984a ; MacKay 1988 ; Mattioli 2014 ; Meikle 1979 ; Pulvermuller 2001 ; SEMaFORE ; Shewan 1984i ; Shewan 1984ii ; Shewan 1984iii ; Sickert 2014 ; Smania 2006 ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; VERSE II ; Wertz 1981 ; Wertz 1986i ; Wertz 1986ii ; Wertz 1986iii ). We were unable to clarify the number of drop‐outs in three trials ( Conklyn 2012 ; FUATAC ; Szaflarski 2014 ). All randomised participants were included in the final analyses for the remaining 31 trials.

Other potential sources of bias

Some trials that compared the effects of SLT with no SLT also reported co‐interventions. Two groups that received SLT also received acupuncture ( Liu 2006a ; Zhang 2007ii ). Some participants in Doesborgh 2004 received additional psychosocial group therapy, and some (or all) of the participants reported in Smith 1981i may have benefited from other intensive treatment as part of the larger multidisciplinary stroke trial. In both cases, the number and allocation of the participants and specific details of the co‐intervention were unavailable. In other cases, not all participants received the planned number of treatment sessions ( Laska 2011 ; Lincoln 1984a ; Smith 1981i ; Smith 1981ii ).

Similarly, 11 trials that compared two different approaches with SLT provision reported that not all participants received the planned number of treatment sessions ( Bakheit 2007 ; Lincoln 1982i ; Lincoln 1982ii ; Meikle 1979; MIT 2014i ; MIT 2014ii ; RATS‐2 ; Smith 1981iii ; SP‐I‐RiT ; VERSE I ; VERSE II ). Meikle 1979 reported that 5 of the 16 participants receiving conventional SLT missed up to half of their possible treatment. Six trials comparing a high‐intensity SLT with a low‐intensity SLT also reported difficulties providing intensive SLT interventions as planned. For example, Bakheit 2007 reported that only 13 of the 51 participants received 80% or more of the planned intensive intervention. Smith 1981iii reported that participants allocated to intensive therapy only received an average of 21 hours of therapy compared to the planned minimum of 50 hours during the first three months. Such difficulties in maintaining a clear distinction between the two treatment groups has significant implications when evaluating the results and considering the clinical implications of such treatment regimens. Similarly, VERSE I found that six individuals did not reach the intensive SLT intervention target of 2.5 hours, but they also reported that resource limitations in the conventional acute care service meant that 23 individuals in the usual care group failed to receive the maximum once weekly therapy as allocated. ORLA 2010 reported difficulty maintaining a consistent intensity of treatment across two treatment arms, with some participants choosing to have more of the allocated 24 treatment sessions per week than others.

Though all the speech and language therapists in Hinckley 2001 received training in the characteristics of the two treatment approaches being compared, treatment review processes were in place to minimise any possible risk of overlap in therapy approach. ACTNoW 2011 , Woolf 2015i , Woolf 2015ii , and Woolf 2015iii employed a similar monitoring approach to ensure fidelity to the planned interventions. The computer‐based intervention used in Varley 2016i and Varley 2016ii recorded the self directed computer treatment activity and duration. Data from three randomised comparisons were subgroups of participants with aphasia extracted from within a larger trial examining models of stroke care ( Smith 1981i ; Smith 1981ii ; Smith 1981iii ). Being part of a larger stroke trial may have affected their levels of fatigue and ability to participate fully in the SLT intervention. The main trial described the inclusion of 20 participants with mild dementia, but it is unclear whether any of these individuals were included in the aphasia‐specific data.

Effects of interventions

See: Table 1 ; Table 2 ; Table 3 ; Table 4 ; Table 5

The results of this review are presented below within the three comparisons: SLT versus no SLT, SLT versus social support and stimulation, and SLT A versus SLT B. Where data availability permitted, we also report results from meta‐analyses. As described in the Measures of treatment effect section, we extracted the final value scores for inclusion within this review whenever possible. Change‐from‐baseline data were also available for three trials, but we do not present them in the review ( Denes 1996 ; Hinckley 2001 ; RATS ).

Comparison 1: SLT versus no SLT

A total of 1620 participants were randomised across 27 comparisons that assessed SLT versus no SLT ( B.A.Bar 2011i ; CACTUS 2013 ; Conklyn 2012 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Lincoln 1984a ; Liu 2006a ; Lyon 1997 ; MacKay 1988 ; Mattioli 2014 ; Smania 2006 ; Smith 1981i ; Smith 1981ii ; Szaflarski 2014 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Wu 2004 ; Wu 2013 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). Reporting of age and other participant characteristics varied between trials, making it difficult to give an overview of the participants involved in this comparison. Eight trials reported age ranges, spanning 28 to 94 years of age ( CACTUS 2013 ; Laska 2011 ; Lincoln 1984a ; Lyon 1997 ; Mattioli 2014 ; Smania 2006 ; Varley 2016i ; Wu 2004 ), while others reported participants' mean age or age bands ( Table 6 ). Nineteen trials reported the length of time since onset of aphasia: spanning from two days in Mattioli 2014 to 29 years in CACTUS 2013 . The shortest mean length of time since the onset of participants' aphasia was 2.2 (SD 1.3) days ( Mattioli 2014 ). Fourteen trials reported severity of aphasia ( B.A.Bar 2011i ; CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Liu 2006a ; Mattioli 2014 ; Smith 1981i ; Smith 1981ii ; Wertz 1986i ; Wertz 1986ii ; Zhang 2007i ; Zhang 2007ii ), although three additional trials provided some indication of severity of impairment ( Conklyn 2012 ; Lyon 1997 ; Smania 2006 ) ( Table 6 ).

Among the SLT interventions compared to a 'no SLT' group were interventions considered to be conventional SLT ( Liu 2006a ; Mattioli 2014 ; Smania 2006 ; Smith 1981ii ; Wertz 1986i ; Wu 2004 ; Wu 2013 ; Xie 2002 ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ), computer‐mediated SLT ( B.A.Bar 2011i ; CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Varley 2016i ), group SLT ( Yao 2005i ), functional SLT ( Lyon 1997 ), intensive SLT ( Laska 2011 ; Smith 1981i ; Szaflarski 2014 ), language enrichment therapy ( Laska 2011 ), constraint‐induced aphasia therapy ( Szaflarski 2014 ), melodic intonation therapy ( Conklyn 2012 ), SLT plus operant training ( Lincoln 1984a ), independent training ( B.A.Bar 2011i ; Varley 2016i ), and volunteer‐facilitated SLT ( CACTUS 2013 ; MacKay 1988 ; Wertz 1986ii ). We planned to conduct a sensitivity analysis on trials that involved the provision of SLT by non‐speech and language therapists ( Conklyn 2012 ; Liu 2006a ; MacKay 1988 ; Wertz 1986ii ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ), but because of the present availability of data within each outcome, it was not useful to undertake this analysis.

Appropriate summary data for communication outcomes (allowing inclusion in the meta‐analyses) were available for 17 of the 27 trials ( B.A.Bar 2011i ; CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Liu 2006a ; Lincoln 1984a ; Mattioli 2014 ; Smania 2006 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Yao 2005i ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). In addition, Lincoln 1984a also reported statistical data for psychosocial outcomes. Suitable communication outcome summary data were not reported (or available on request) for the remaining nine trials ( Conklyn 2012 , Lyon 1997 ; MacKay 1988 ; Szaflarski 2014 ; Smith 1981i ; Smith 1981ii ; Wu 2004 ; Wu 2013 ; Xie 2002 ). However, Xie 2002 presented some summary data in a table that indicated language function at end of the trial intervention on a scale (no effect, progress, obvious effect, recovery), and using this data, we constructed means and standard deviation data by assigning numerical values (0 to 3) to each scale point. However, we noted that the presentation of the table did not match the description of results in the text; in fact, the table reported an adverse intervention effect and deterioration over time, which we believe was an error that was rectified by inverting the scale reported. Where data for this comparison were available, we present them below in relation to: functional communication, receptive language, expressive language, severity of impairment, psychosocial impact, number of dropouts, adherence to allocated intervention, and economic outcomes.

1. Functional communication

Thirteen trials compared participants that received SLT with those that did not, by measuring functional communication outcomes ( B.A.Bar 2011i ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Mattioli 2014 ; Laska 2011 ; Lincoln 1984a ; Lyon 1997 ; MacKay 1988 ; Wertz 1986i ; Wertz 1986ii ; Zhang 2007i ; Zhang 2007ii ). Tools used included the spontaneous speech subtest of the Western Aphasia Battery (WAB) ( Katz 1997i ; Katz 1997ii ), the Amsterdam‐Nijmegen Everyday Language Test (ANELT) ( B.A.Bar 2011i ; Doesborgh 2004 ; Laska 2011 ), the AAT (spontaneous speech) ( Mattioli 2014 ) the Communication Activities of Daily Living (CADL) ( Wertz 1986i ; Wertz 1986ii ), the Functional Communication Profile (FCP) ( Lincoln 1984a ; Wertz 1986i ; Wertz 1986ii ), the Aachen‐Sprach‐Analysis ( B.A.Bar 2011i ), and the Chinese Functional Communication Profile ( Zhang 2007i ; Zhang 2007ii ). Ten trials provided suitable statistical data permitting inclusion within the meta‐analyses ( B.A.Bar 2011i ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Mattioli 2014 ; Wertz 1986i ; Wertz 1986ii ; Zhang 2007i ; Zhang 2007ii ).

Spontaneous speech

Six trials evaluated the impact of SLT by contrasting the spontaneous speech of participants. Intervention groups received computer‐mediated SLT in four trials ( B.A.Bar 2011i ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ), and they received language enrichment therapy in two ( Laska 2011 ; Mattioli 2014 ). Control groups received no intervention in Doesborgh 2004 , Katz 1997i , Laska 2011 , and Mattioli 2014 , and they received computer‐mediated non‐linguistic tasks in B.A.Bar 2011i and Katz 1997ii ). Investigators carried out comparisons using a subtest of the WAB ( Katz 1997i ; Katz 1997ii ), the ANELT ( B.A.Bar 2011i ; Doesborgh 2004 ; Laska 2011 ), or the AAT ( Mattioli 2014 ).

Communication Activities of Daily Living (CADL)

Four trials used the CADL to compare the functional communication skills of participants that received conventional SLT ( Wertz 1986i ), volunteer‐facilitated SLT ( MacKay 1988 ; Wertz 1986ii ), and functional SLT ( Lyon 1997 ), versus those that received no SLT intervention. Two trials provided statistical data that allowed inclusion within a meta‐analysis ( Wertz 1986i ; Wertz 1986ii ).

Functional Communication Profile (FCP)

Three trials compared the pragmatic provision of SLT (approach tailored to individual participants' needs) to a deferred SLT intervention using the FCP ( Lincoln 1984a ; Wertz 1986i ; Wertz 1986ii ). Appropriate summary data for Lincoln 1984a on this outcome measure were not available.

Chinese Functional Communication Profile (CFCP)

Zhang 2007i and Zhang 2007ii used the CFCP to compare groups that received SLT and no SLT. One SLT group also received an acupuncture co‐intervention and scored higher on the CFCP than those that had received no SLT ( Zhang 2007ii ).

We pooled the results of functional communication measures reported across the trials within a meta‐analysis. We only included one set of functional communication measures from Wertz 1986i and Wertz 1986ii at a time. Participants that received SLT performed better on measures of functional communication than those that did not receive SLT (when including the CADL data: P = 0.03, SMD 0.23, 95% CI 0.02 to 0.44 or when including FCP data: P = 0.01, SMD 0.28, 95% CI 0.06 to 0.49). We have chosen to present the data from the FCP within the forest plot ( Analysis 1.1 ).

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Comparison 1 SLT versus no SLT, Outcome 1 Functional communication.

2. Receptive language

Twelve of the 27 trials measured participants' receptive language skills ( CACTUS 2013 , Katz 1997i ; Katz 1997ii ; Laska 2011 ; Mattioli 2014 ; Smania 2006 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Xie 2002 ; Zhang 2007i ; Zhang 2007ii ), and all but two reported statistical data that permitted inclusion in the meta‐analyses ( Varley 2016i ; Xie 2002 ). We calculated suitable summary data from Xie 2002 's published table of results (as described above). Investigators assessed auditory comprehension using the Token Test and subtests of the WAB, the Norsk Grunntest for Afasi (NGA), the Aphasia Battery of Chinese (ABC), the Comprehensive Aphasia Test (CAT), and the PICA. Reading comprehension was measured using the Reading Comprehension Battery for Aphasia (RCBA) and the reading subtests of the PICA, the CAT, and the ABC. Gesture comprehension was measured using an unnamed assessment.

Auditory comprehension

Five trials used the Token Test to measure changes in participants' auditory comprehension ( CACTUS 2013 , Mattioli 2014 ; Smania 2006 ; Wertz 1986i ; Wertz 1986ii ). Two trials used the ABC auditory comprehension subtest ( Zhang 2007i ; Zhang 2007ii ). Laska 2011 reported using the NGA, CACTUS 2013 the CAT spoken word and spoken sentence subtests, and Mattioli 2014 the AAT subtest. Two trials used both the WAB and PICA subtests to measure participants' auditory comprehension ( Katz 1997i ; Katz 1997ii ). We could not include both sets of data from Katz 1997i ; Katz 1997ii , CACTUS 2013 and Mattioli 2014 in the same meta‐analysis. On pooling the data within two separate meta‐analyses, there was no evidence of a significant difference between the groups. We have chosen to present the PICA ( Katz 1997i ; Katz 1997ii ), the CAT (spoken sentence comprehension subtest), and Token Test data ( Mattioli 2014 ) within the forest plot ( Analysis 1.2 ). For pooled analyses using the Mattioli 2014 AAT data and the Katz 1997i and Katz 1997ii WAB data, there was no evidence of a difference between the groups (P = 0.57, SMD 0.06, 95% CI −0.15 to 0.26).

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Comparison 1 SLT versus no SLT, Outcome 2 Receptive language: auditory comprehension.

Reading comprehension

Nine trials assessed reading comprehension, comparing participants that received SLT and those that did not ( CACTUS 2013 , Katz 1997i ; Katz 1997ii ; Meikle 1979 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Zhang 2007i ; Zhang 2007ii ). Two trials used the RCBA to compare participants that received volunteer‐facilitated SLT with those that received no SLT ( Wertz 1986i ; Wertz 1986ii ). Similarly, two trials used the PICA reading subtest to compare participants that received computer‐mediated SLT to those that received no treatment or computer‐mediated non‐linguistic tasks ( Katz 1997i ; Katz 1997ii ). Another three trials compared the performance of participants that received SLT with those that did not using the reading subtest of the ABC ( Zhang 2007i ; Zhang 2007ii ), subtests from the CAT (written word or sentence comprehension; CACTUS 2013 ), or the AAT reading comprehension subtest ( Mattioli 2014 ). Varley 2016i did not report data suitable for inclusion in the meta‐analysis. The participants that received SLT in Zhang 2007ii also received an acupuncture co‐intervention. On pooling of the available data with the CAT data on written word comprehension, the participants that received SLT performed better on tests of reading comprehension than those that did not receive SLT (P = 0.03, SMD 0.29, 95% CI 0.03 to 0.55; CACTUS 2013 ; Analysis 1.3 ). If pooling data from CACTUS 2013 CAT subtest of written sentence comprehension, there was no longer evidence of a difference between the groups (P = 0.05; SMD 0.03, 95% CI 0.00 to 0.52). Plotting these outcome measures against the estimated standard errors within a funnel plot, we found that the result from one of the trials based on the ABC fell outside the 95% CI ( Figure 4 ). We will consider this issue further in the Discussion section.

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Funnel plot of comparison: 1 SLT versus no SLT, outcome: 1.3 Receptive language: reading comprehension.

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Comparison 1 SLT versus no SLT, Outcome 3 Receptive language: reading comprehension.

Other comprehension

Four trials used the PICA gestural subtest, which measures gestural abilities alongside auditory and written comprehension skills ( Katz 1997i ; Katz 1997ii ; Wertz 1986i ; Wertz 1986ii ). Xie 2002 employed the Chinese Language Impairment Examination. Following pooling, participants that received SLT had achieved higher scores on measures of gesture use than the groups that received no SLT (P = 0.03, SMD 1.23, 95% CI 0.11 to 2.36). However, we also observed significant heterogeneity (P < 0.00001; I 2 = 91%) which was no longer observed when the Xie 2002 data was removed from the meta‐analysis, al though this did not impact on the findings (P = 0.04, SMD 0.34, 95% CI 0.01 to 0.67) ( Analysis 1.4 ).

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Comparison 1 SLT versus no SLT, Outcome 4 Receptive language: other.

3. Expressive language

Twelve trials formally evaluated participants' expressive language skills using single word picture naming (Boston Naming Test (BNT), the WAB and NGA naming subtests, the AAT, the Object and Action Naming Battery or other naming tests), repetition (WAB and NGA repetition subtests), and other verbal expression (PICA and ABC sub tests) skills ( CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 ; Mattioli 2014 ; Szaflarski 2014 ; Varley 2016i ; Wertz 1986i ; Wertz 1986ii ; Zhang 2007i ; Zhang 2007ii ). Written language expressive skills were measured using the PICA copying and writing subtests and the ABC writing subtest, while the ability to communicate using gesture was measured using the PICA gesture subtest.

Expressive language: naming

Eight trials measured participants' naming abilities ( CACTUS 2013 ; Doesborgh 2004 ; Katz 1997i ; Katz 1997ii ; Laska 2011 Mattioli 2014 ; Szaflarski 2014 ; Varley 2016i ). Three trials used the BNT or naming accuracy (treated, matched and control items) to compare a group receiving computer‐mediated SLT or constraint‐induced aphasia therapy versus a group that did not receive SLT ( Doesborgh 2004 ; Szaflarski 2014 ; Varley 2016i ). Data from Szaflarski 2014 were not available at the time of this review. Katz 1997i and Katz 1997ii employed the WAB naming subtest, while Laska 2011 used the NGA naming subtest, Mattioli 2014 used the AAT subtest, and CACTUS 2013 used items from the Object and Action Naming Battery. On pooling, there was no evidence of a difference between the groups regardless of whether the treated, matched or control items from Varley 2016i were included in the analysis. We present the meta‐analysis that includes the matched items from Varley 2016i (P = 0.26, SMD 0.14, 95% CI −0.10 to 0.38; Analysis 1.5 ).

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Comparison 1 SLT versus no SLT, Outcome 5 Expressive language: naming.

Expressive language: general

Five trials used the PICA verbal subtest to compare the spoken language skills of patient groups that received SLT and those that did not ( Katz 1997i ; Katz 1997ii ; Wertz 1986i ; Wertz 1986ii ; Xie 2002 ). Two additional trials captured participants' expressive language skills using a subtest of the ABC ( Zhang 2007i ; Zhang 2007ii ). On pooling the data using SMDs, there was evidence of significant statistical heterogeneity between the groups (P < 0.00001; I 2 = 89%), so we used a random‐effects model to pool the data. Participants that had received SLT scored significantly better on general measures of expressive language skills (P = 0.005, SMD 1.28, 95% CI 0.38 to 2.19) ( Analysis 1.6 ). Conducting a sensitivity analysis, we found that when we removed Xie 2002 , Zhang 2007i , and Zhang 2007ii from the analysis, the heterogeneity disappeared (I 2 = 0%), and the pooled results no longer demonstrated a significant difference between the groups. We will consider this issue further in the Discussion section.

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Comparison 1 SLT versus no SLT, Outcome 6 Expressive language: general.

Expressive language: written

Eight trials reported comparing a group receiving SLT with a group receiving no SLT using writing subtests of the PICA ( Katz 1997i ; Katz 1997ii ), the ABC ( Zhang 2007i ; Zhang 2007ii ), the AAT ( Mattioli 2014 ), the CAT ( CACTUS 2013 ), and the PICA graphic subtest ( Wertz 1986i ; Wertz 1986ii ). Following pooling, participants that had received SLT performed better on the writing subtests than those that had not received SLT (P = 0.003, SMD 0.41, 95% CI 0.14 to 0.67) ( Analysis 1.7 ). Plotting these outcome measures against the estimated standard errors within a funnel plot, we found that the result from one of the trials based on the ABC fell outside the 95% CI ( Figure 5 ). We will consider this issue further in the Discussion section.

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Funnel plot of comparison: 1 SLT versus no SLT, outcome: 1.7 Expressive language: written.

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Comparison 1 SLT versus no SLT, Outcome 7 Expressive language: written.

Expressive language: copying text

Two trials compared a group receiving computer‐mediated SLT with a group receiving no SLT or a group receiving computer‐mediated non‐linguistic tasks using the PICA copying subtest ( Katz 1997i ; Katz 1997ii ). There was no evidence of a difference between the groups' copying skills ( Analysis 1.8 ).

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Comparison 1 SLT versus no SLT, Outcome 8 Expressive language: written copying.

Expressive language: repetition

Four trials compared participants that received SLT and those that did not by measuring their repetition skills on the WAB subtest ( Katz 1997i ; Katz 1997ii ), the NGA subtest ( Laska 2011 ), and a repetition accuracy test ( Varley 2016i ). Following pooling of the available data (using the matched items from Varley 2016i ), there was no evidence of a difference in the participants' repetition skills ( Analysis 1.9 ). This did not alter if the treated or control items were used from Varley 2016i .

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Comparison 1 SLT versus no SLT, Outcome 9 Expressive language: repetition.

Expressive language: fluency

B.A.Bar 2011i measured changes in word fluency using the Regensburg Word Fluency Test (food and animals). Szaflarski 2014 used the Semantic Fluency Test, but there were no data available. There was no evidence of a difference between the groups ( Analysis 1.10 ).

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Comparison 1 SLT versus no SLT, Outcome 10 Expressive language: fluency.

4. Severity of impairment

Seventeen trials compared a group that received SLT with one that did not receive any SLT by measuring the severity of the participants' aphasia impairment. Language assessment batteries included the PICA ( Katz 1997i ; Katz 1997ii ; Lincoln 1984a ; Wertz 1986i ; Wertz 1986ii ), the Boston Diagnostic Aphasia Examination (BDAE) ( Liu 2006a ; Lyon 1997 , Wu 2013 ), the Chinese Aphasia Measurement ( Zhao 2000 ), the WAB ( Katz 1997i ; Katz 1997ii ; Wu 2013 ), the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA) ( Smith 1981i ; Smith 1981ii ), the NGA ( Laska 2011 ), the Chinese Rehabilitation Research Centre Aphasia Examination (CRRCAE) ( Wu 2013 ; Yao 2005i ; Yao 2005ii ), the Aphasia Battery of Chinese (ABC) ( Zhang 2007i ; Zhang 2007ii ), and the Chinese Language Impairment Examination ( Xie 2002 ). Included trials compared the severity of participants' aphasia between groups that received group SLT ( Yao 2005i ), computer‐mediated SLT ( Katz 1997i ; Katz 1997ii ), conventional SLT ( Liu 2006a ; Wertz 1986i ; Wu 2013 , Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ), language training ( Xie 2002 ), and volunteer‐facilitated SLT ( Wertz 1986ii ), versus groups that received no SLT or a computer‐mediated non‐SLT intervention ( Katz 1997ii ). We were able to obtain statistical summary data suitable for inclusion within a meta‐analysis from all but six trials ( Lincoln 1984a ; Lyon 1997 ; Smith 1981i ; Smith 1981ii ; Xie 2002 ; Wu 2013 ).

Pooling the available data (selectively including the PICA data from Katz 1997i and Katz 1997ii ) using SMDs, we observed significant heterogeneity (I 2 = 93%, P < 0.00001). Thus, we pooled the data using a random‐effects model. The heterogeneity remained. There was no evidence of a significant difference between the groups that received SLT and those that did not ( Analysis 1.11 ). On conducting a sensitivity analysis to identify the source of the heterogeneity, we observed that removing the Zhao 2000 data from the meta‐analysis eliminated the heterogeneity (I 2 = 0%). The pooled data also demonstrated no significant difference between the aphasia severity ratings between the groups regardless of whether the PICA data from Katz 1997i and Katz 1997ii were included (P = 0.08, SMD 0.17, 95% CI −0.02 to 0.36). Conducting the same analysis but including the WAB data from Katz 1997i and Katz 1997ii resulted in no evidence of a significant difference between the groups (P = 0.09, SMD 0.15, 95% CI −0.04 to 0.34). We have chosen to present the PICA data ( Analysis 1.11 ). The funnel plot of Analysis 1.11 ( Figure 6 ) showed that the outcome based on the Chinese Aphasia Measurement fell outside the 95% CI. We will return to this issue within the Discussion section.

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Funnel plot of comparison: 1 SLT versus no SLT, outcome: 1.11 Severity of impairment: Aphasia Battery Score (+ PICA).

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Comparison 1 SLT versus no SLT, Outcome 11 Severity of impairment: Aphasia Battery Score (+ PICA).

Five trials compared the benefits of an SLT intervention to no SLT by employing psychosocial measures including the Multiple Affect Adjective Checklist (MAACL), the General Health Questionnaire (GHQ), the Affect Balance Scale (ABS), the Psychological Wellbeing Index, the EuroQoL, and the Nottingham Health Profile (NHP) ( Laska 2011 ; Lincoln 1984a ; Lyon 1997 ; Smith 1981i ; Smith 1981ii ).

Lyon 1997 used the ABS and Psychological Wellbeing Index to compare a group of triads (person with aphasia, caregiver and communication partner) that received functional SLT aiming to establish and maximise effective means of communication between communication partners and a group that received no SLT. Smith 1981i and Smith 1981ii used the GHQ to compare groups that received either intensive SLT or conventional SLT with a group that received no treatment, while Laska 2001 reported capturing data using the EuroQol and the NHP. No suitable data were available from these trials. In contrast, Lincoln 1984a used the anxiety, depression and hostility scales of the MAACL to compare the psychosocial well‐being of a group that received SLT (determined by the therapist) with a group that received no SLT. Comparison of the groups failed to show any evidence of a difference in the participants' anxiety, depression or hostility as measured on these scales ( Analysis 1.12 ).

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Comparison 1 SLT versus no SLT, Outcome 12 Mood: MAACL.

6. Number of dropouts

Information relating to the numbers of participant dropouts (where they occurred) was available for all but two trials in this comparison ( Conklyn 2012 , Szaflarski 2014 ). A total of 235 individuals withdrew during the treatment phase . Thirteen trials reported no withdrawals ( B.A.Bar 2011i ; CACTUS 2013 ; Liu 2006a ; Lyon 1997 ; Mattioli 2014 ; Wu 2004 ; Wu 2013 , Xie 2002 , Yao 2005i ; Yao 2005ii ; Zhang 2007i ; Zhang 2007ii ; Zhao 2000 ). An additional five participants withdrew from Smith 1981i and Smith 1981ii (group allocation is unclear, but these withdrawals are included in the number above), and they failed to report the number of withdrawals from the 'no SLT' group. There was a range of reasons for the attrition of participants from the trials (see Table 7 for details). On pooling of the available data relating to dropouts, there was no evidence of a difference between the groups ( Analysis 1.14 ).

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Comparison 1 SLT versus no SLT, Outcome 14 Number of dropouts (any reason).

7. Adherence to allocated intervention

Only 5 of the 15 trials reporting participant dropouts described the reasons for the 26 participants' withdrawal ( CACTUS 2013 ; Doesborgh 2004 ; Laska 2011 ; Smania 2006 ; Varley 2016i ). Of these, a total of 21 participants were described as withdrawing because they were uncooperative or they refused the allocated treatment with nine withdrawing from the conventional SLT group and 12 withdrawing from the 'no SLT' group. Four participants in Laska 2011 refused testing (one from the SLT group; three from the no SLT group). Details can be found in Table 7 . On pooling there was no indication of a difference in adherence rates between the groups.

8. Economic outcomes

Two of the 19 randomised comparisons described the measurement of economic outcomes: MacKay 1988 using structured questionnaires and CACTUS 2013 the EQ‐5D (and the patient visual analogue scale (VAS)) and resource use (diary based). Only data from CACTUS 2013 were available for this review, and there was no evidence of a difference between the groups ( Analysis 1.13 ).

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Comparison 1 SLT versus no SLT, Outcome 13 Economic outcomes.

9. Follow‐up data (comparison 1: SLT versus no SLT)

Eight trials comparing SLT versus no SLT also gathered data at a follow‐up point after the formal intervention period. Of these trials, B.A.Bar 2011ii and Szaflarski 2014 did not report data suitable for inclusion in the review, while data from the remaining six trials are presented below in relation to: functional communication, receptive language, expressive language, severity of impairment, number of dropouts, and adherence to allocated intervention ( CACTUS 2013 ; Laska 2011 , Mattioli 2014 ; Smania 2006 ; Yao 2005i ; Yao 2005ii ).

Both Laska 2011 and Mattioli 2014 measured functional communication at six months using the ANELT and the AAT and compared performance of people who received SLT and those that did not. There was no evidence of a difference between the groups ( Analysis 2.1 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 1 Functional communication.

Participants' auditory comprehension six months following intervention was compared using the AAT subtest ( Mattioli 2014 ), the Token Test ( Mattioli 2014 ), and the NGA ( Laska 2011 ). To avoid double‐counting the Mattioli 2014 trial data, we presented the pooled data using the AAT auditory comprehension subtest data ( Analysis 2.2 ). There was no evidence of a difference between the groups. We obtained similar findings in the meta‐analysis using the Token Test (P = 0.45; 1.24 CI 95% −1.94 to 4.41).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 2 Receptive language: auditory comprehension.

Mattioli 2014 also assessed reading in participants receiving SLT versus no SLT using the AAT subtest; there was no evidence of a different between the groups ( Analysis 2.3 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 3 Receptive language: reading comprehension.

4. Expressive language

CACTUS 2013 evaluated the naming abilities of participants who had received SLT versus those that had not at three months follow‐up using items from the Object and Action Naming Battery, while at six months, Laska 2011 used the NGA, and Mattioli 2014 the AAT naming subtest ( Analysis 2.4 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 4 Expressive language: naming.

Similarly, Mattioli 2014 used the AAT written subtest to evaluate writing abilities ( Analysis 2.5 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 5 Expressive language: written.

Mattioli 2014 and Laska 2011 also assessed repetition abilities using the AAT repetition subtest and the NGA, respectively, at six months after intervention ( Analysis 2.6 ). There was no evidence of a difference between the groups on any of these measures of expressive language ability at three or six months' follow‐up.

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 6 Expressive language: repetition.

5. Severity of impairment

At six months follow‐up, Laska 2011 compared the severity of participants' aphasia using the NGA, and Yao 2005i and Yao 2005ii used the CRRCAE Aphasia Quotient. On pooling the data, there was no evidence of a difference between the groups ( Analysis 2.7 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 7 Severity of impairment: Aphasia Battery Score.

6. Economic outcomes

The CACTUS 2013 trial captured EQ‐5D and Patient VAS data at three‐month follow‐up after the end of treatment and found no evidence of a difference between the groups ( Analysis 2.8 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 8 Economic outcomes.

7. Number of dropouts

Six trials also reported attrition from the follow‐up data collection point ( CACTUS 2013 ; Laska 2011 , Smania 2006 , Mattioli 2014 ; Wertz 1986i , Wertz 1986ii ). Of 181 participants receiving SLT, 21 were reported as lost to follow‐up, while 25 of the 136 people who did not receive SLT were not followed up. There was no evidence of a difference between the groups ( Analysis 2.9 ).

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Comparison 2 SLT versus no SLT (follow‐up data), Outcome 9 Number of dropouts (any reason).

Comparison 2: SLT versus social support and stimulation

Nine trials compared the provision of SLT to the provision of informal social support and stimulation in a total of 447 participants ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Lincoln 1982iii ; Rochon 2005 ; Shewan 1984ii ; Shewan 1984iii , Woolf 2015ii ; Woolf 2015iii ). Descriptions of participant groups within trials were variable, so it is difficult to give a precise overview of the participants included in this comparison. Most trials described the participants' age range, which spanned from 18 to 97 years ( ACTNoW 2011 ; Elman 1999 ; Lincoln 1982iii ; Rochon 2005 ; Shewan 1984ii ; Shewan 1984iii ). David 1982 reported that participants in the SLT and social support and stimulation groups had a mean age of 70 (SD 8.7) years and 65 (SD 10.6) years, respectively, indicating a significant difference between the groups (P = 0.003). Details can be found in Table 6 . All nine trials detailed the length of time since aphasia onset. ACTNoW 2011 randomised participants with the most acute aphasia (interquartile range (IQR) 9 to 16 days duration). Similarly, Shewan 1984ii and Shewan 1984iii recruited people at two to four weeks post onset of aphasia. In contrast, Lincoln 1982iii recruited participants at 1 to 36 months' poststroke, while Woolf 2015ii and Woolf 2015iii recruited at a mean of 31.8 (14.11) and 35.2 (33.16) months post onset, respectively. Other trials recruited participants much later after stroke, ranging from 2 to 9 years in Rochon 2005 to 7 months to 28 years in Elman 1999 . All nine trials reported on severity of aphasia to varying degrees of detail. Lincoln 1982iii recruited participants with moderate degrees of aphasia. Six trials described the recruitment of participants with a range of mild to severe aphasia ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Rochon 2005 ; Shewan 1984ii ; Shewan 1984iii ), and two trials reported scores on a naming measure ( Woolf 2015ii ; Woolf 2015iii ) ( Table 6 ).

There were a number of approaches to the provision of SLT interventions in the trials: five provided conventional SLT ( ACTNoW 2011 ; David 1982 ; Lincoln 1982iii ; Shewan 1984iii ; Woolf 2015iii ), and the others provided group SLT ( Elman 1999 ), sentence‐mapping SLT ( Rochon 2005 ), language‐orientated SLT ( Shewan 1984ii ), or telerehabilitation SLT ( Woolf 2015ii ). These SLT interventions were then compared with the provision of social support and stimulation, which also took a variety of formats. Unstructured support and communicative stimulation were provided by nurses ( Shewan 1984ii ; Shewan 1984iii ), a trained research assistant ( Rochon 2005 ), a clinical psychologist ( Lincoln 1982iii ), speech and language therapy students ( Woolf 2015ii ; Woolf 2015iii ), paid visitors ( ACTNoW 2011 ; David 1982 ), or through attendance at an externally organised support group or class, for example dance classes or church groups ( Elman 1999 ). Most were face‐to‐face social support. Two used an Internet‐supported videoconferencing tool. Some volunteers had been given detailed information about their own participant's particular presentation of aphasia ( David 1982 ), but they were not given any training in SLT techniques ( ACTNoW 2011 ; David 1982 ; Lincoln 1982iii ; Shewan 1984ii ; Shewan 1984iii ). Two trials had a specific, non‐therapeutic intervention protocol for the people providing the social support and stimulation intervention, which detailed the role and suitable non‐communication therapy activities ( ACTNoW 2011 ; Lincoln 1982iii ). Other providers of social support received a handbook and training in supported conversation ( Woolf 2015ii ; Woolf 2015iii ). Six trials described intervention fidelity monitoring ( ACTNoW 2011 ; Shewan 1984ii ; Shewan 1984iii ; David 1982 ; Woolf 2015ii ; Woolf 2015iii ), together with monitoring of a percentage of the overall sessions in three of these ( David 1982 ; Woolf 2015ii ; Woolf 2015iii ). The participants in these groups received social support for up to one hour ( ACTNoW 2011 ; Rochon 2005 ), two hours ( David 1982 ; Lincoln 1982iii ; Woolf 2015ii ; Woolf 2015iii ), or three hours ( Elman 1999 ; Shewan 1984ii ; Shewan 1984iii ), each week over a period of up to 1 month ( Lincoln 1982iii ; Woolf 2015ii ; Woolf 2015iii ), 2.5 months ( Rochon 2005 ), 4 months ( ACTNoW 2011 ; Elman 1999 ), 5 months ( David 1982 ), or one year ( Shewan 1984ii ; Shewan 1984iii ). Statistical data for communication outcomes were available for six of the included trials ( ACTNoW 2011 ; David 1982 ; Lincoln 1982iii ; Rochon 2005 ; Woolf 2015ii ; Woolf 2015iii ). Suitable data allowing inclusion within the meta‐analyses were unavailable for the remaining three trials ( Elman 1999 ; Shewan 1984ii ; Shewan 1984iii ). We report the comparisons made (with meta‐analysis where possible) below as they relate to measures of: functional communication, receptive language, expressive language, severity of impairment, psychosocial impact, number of dropouts, adherence to allocated intervention, and economic outcomes.

Five trials measured functional communication using the FCP, the CADL, the CETI, Therapy Outcome Measures (TOMs), and discourse analysis approaches ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Woolf 2015ii ; Woolf 2015iii ).

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Comparison 3 SLT versus social support and stimulation, Outcome 1 Functional communication.

Communication Abilities of Daily Living (CADL) and the Communicative Effectiveness Index (CETI)

Elman 1999 used the CADL, the CETI and measures of connected speech to compare the functional communication skills of participants that received conventional SLT and those that attended social groups and activities instead. The trial did not provide suitable summary data, so we could not include the results in the meta‐analysis.

Therapy Outcome Measures (TOMs)

ACTNoW 2011 used the TOMs to compare blinded ratings of video‐recorded samples of functional communication skills in participants that had received conventional SLT and those that had received social support and stimulation from a volunteer.

Discourse analyses approaches

Two trials used discourse analysis approaches to examine the use of substantive turns, content words per turn and the number of nouns per turn used by participants in a conversational interaction ( Woolf 2015ii ; Woolf 2015iii ). The groups had received either SLT or an Internet‐based conference conversational intervention.

The measure of content words per turn was pooled with the other data in Analysis 3.1 , and there was no evidence of a significant difference between the groups that had received SLT and those that had received informal social support. Pooling using the other discourse measures made no difference to this finding.

Four of the nine trials that compared participants that received SLT or a social support and stimulation intervention did so by comparing the groups' receptive language skills ( Lincoln 1982iii ; Rochon 2005 ; Shewan 1984ii ; Shewan 1984iii ). Measures used included the Philadelphia Comprehension Battery (PCB), the Auditory Comprehension Test for Sentences (ACTS), the Token Test and the PICA gestural subtest.

Philadelphia Comprehension Battery (PCB)

Rochon 2005 measured participants' receptive language skills on the PCB, which includes subtests for sentence comprehension and picture comprehension. There was no evidence of a difference between the receptive language skills of the participants that received sentence‐mapping SLT and those that received unstructured social support and stimulation ( Analysis 3.2 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 2 Receptive language: auditory comprehension.

Auditory Comprehension Test for Sentences (ACTS)

Two additional trials measured receptive language skills by measuring auditory comprehension of sentences in participants that received either language‐oriented therapy or conventional SLT versus an intervention that provided unstructured social support ( Shewan 1984ii ; Shewan 1984iii ). Both trials used the ACTS to make this comparison, but the manner in which they reported data prevented inclusion within the meta‐analysis.

Lincoln 1982iii measured participants' receptive language skills using the Token Test. There was no evidence of a difference between the groups ( Analysis 3.2 ).

Receptive language: other comprehension

Lincoln 1982iii assessed participants' auditory and written comprehension skills using the PICA gestural subtest; those that had access to social support and stimulation performed significantly better on these measures than those that had access to SLT (P = 0.04, MD −0.87, 95% CI −1.70 to −0.04) ( Analysis 3.3 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 3 Receptive language: other.

Five of the nine trials that compared participants that received SLT or a social support and stimulation intervention did so by comparing the groups' expressive language skills ( Elman 1999 ; Lincoln 1982iii ; Rochon 2005 ; Woolf 2015ii ; Woolf 2015iii ). Measures used included the Object Naming Test (ONT), Caplan and Hanna Sentence Production Test (CHSPT), the Picture Description with Structured Modeling (PDSM), the PICA and the Spoken Picture Naming Test.

Expressive language: single words

Lincoln 1982iii measured participants' naming skills on the ONT, while Woolf 2015ii and Woolf 2015iii used the Spoken Picture Naming test. On pooling the data, there was no evidence of a difference between the groups that received social support and stimulation and those that had received SLT, but there was significant heterogeneity (P = 0.0002; I 2 = 84%) ( Analysis 3.4 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 4 Expressive language:naming.

Expressive language: sentences

Rochon 2005 compared the participants who received s entence‐mapping SLT and a group receiving unstructured social support and stimulation. Comparison of the two groups showed no evidence of a difference between the groups' performance on the CHSPT scores. Those that had received SLT did perform significantly better on treated items from the test (P = 0.01, MD 3.00, 95% CI 0.63 to 5.37) than the participants who received social support, but there was no evidence of a difference between the groups on the untreated items ( Analysis 3.5 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 5 Expressive language: sentences.

Expressive language: picture description

Two trials elicited samples of participants' connected speech using picture description tasks ( Lincoln 1982iii ; Rochon 2005 ). There was no evidence of a difference between the two groups. Rochon 2005 also reported the two groups' scores on the treated and untreated items, but there was no evidence of a between‐group difference on the treated or untreated items ( Analysis 3.6 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 6 Expressive language: picture description.

Lincoln 1982iii and Elman 1999 compared the groups' performances on the PICA verbal subtest. Suitable statistical data were unavailable from Elman 1999 , so we could not include the results in the meta‐analysis. Participants who had received social support and stimulation scored significantly better than those who received SLT (P = 0.0007, MD −1.56, 95% CI −2.46 to −0.66) ( Analysis 3.7 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 7 Expressive language: overall spoken.

Similarly, Lincoln 1982iii compared the groups' performances on the PICA graphic subtests and found participants that received social support performed significantly better than those that had received SLT (P = 0.01, MD −1.39, 95% CI −2.49 to −0.29) ( Analysis 3.8 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 8 Expressive language: written.

Expressive language: word fluency

Participants that received social support performed significantly better on measures of word fluency than those that had received SLT ( Lincoln 1982iii ; Analysis 3.9 )

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Comparison 3 SLT versus social support and stimulation, Outcome 9 Expressive language: fluency.

Elman 1999 , Lincoln 1982iii , Shewan 1984ii and Shewan 1984iii compared groups that had access to SLT and those that received social support and stimulation by measuring participants' aphasia severity. The assessments used included the PICA and the Western Aphasia Battery‐Aphasia Quotient (WABAQ).

Two trials used the Shortened PICA to compare participants who had received group SLT and those who had attended other social activities or groups that provided social support and stimulation ( Elman 1999 ; Lincoln 1982iii ). Suitable statistical data were unavailable from Elman 1999 , so we could not include them in the meta‐analysis. Lincoln 1982iii found that participants provided with social support and stimulation were less impaired as a result of aphasia (as measured on the PICA) than those who received SLT (P = 0.005, MD −1.13, 95% CI −1.91 to −0.35). Suitable summary data were not available from Elman 1999 to allow inclusion within the meta‐analysis ( Analysis 3.10 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 10 Severity of impairment: Aphasia Battery Score.

Two additional trials assessed the severity of participants' aphasia using the WAB, comparing participants who received language‐oriented SLT or conventional SLT versus psychological support and unstructured communication provided by trained nurses ( Shewan 1984ii ; Shewan 1984iii ). Suitable summary data were unavailable, so we could not include them in the meta‐analysis.

5. Psychosocial impact

ACTNoW 2011 and Elman 1999 evaluated psychosocial impact in participants who had received SLT versus social support and stimulation using the ABS and the Communication Outcomes After STroke (COAST) scale from both the patients' and caregivers' perspectives.

Affect Balance Scale

Elman 1999 compared participants that had received SLT and those that had received social support using the ABS, but appropriate summary values were unavailable, so we could not include them in the meta‐analysis.

Participants and caregivers completed separate versions of the COAST scale to indicate the impact of the participant's aphasia on their functional communication and quality of life ( ACTNoW 2011 ). Measures were then used to compare the participants that had received SLT and those that had received social support. There was no evidence of a difference between the groups on this measure as reported by the participants or by the caregivers ( Analysis 3.11 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 11 Psychosocial impact.

Six of the nine trials in this section reported dropouts from the original randomised participants ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Lincoln 1982iii ; Shewan 1984ii ; Shewan 1984iii ). The main Lincoln 1982 trial (from which the randomised comparison Lincoln 1982iii has been extracted) excluded 13 participants for failing to complete the full treatment intervention. It is unclear which intervention arms these participants were randomised to, so we could not include these dropouts in meta‐analysis. The remaining trials lost a total of 40 participants from the groups allocated to SLT while 65 were lost to the social support and stimulation interventions. Fewer participants allocated to SLT were lost to the trial than those that were allocated to social support and stimulation (P = 0.005, OR 0.51 95% CI 0.32 to 0.81) ( Analysis 3.12 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 12 Number of dropouts for any reason.

Five trials with dropouts also described the reasons for the dropouts to allow identification of those who had voluntarily withdrawn from the allocated intervention. A total of 11 participants in the SLT groups and 45 participants in the social support and stimulation intervention groups did not adhere to the allocated intervention ( ACTNoW 2011 ; David 1982 ; Elman 1999 ; Shewan 1984ii ; Shewan 1984iii ) (P < 0.00001, OR 0.18, 95% CI 0.09 to 0.37; Analysis 3.13 ). In addition, David 1982 also described the withdrawal of four more participants from the social support group because of 'volunteer problems' (details can be found in Table 7 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 13 Adherence to allocated intervention.

Only one of the nine trials measured economic outcomes ( ACTNoW 2011 ). The cost favoured the provision of SLT (P < 0.00001, MD −3035.00, 95% CI −4342.44 to −1727.56), while the utility data favoured the social support intervention (P = 0.02, MD 0.06, 95% CI 0.01 to 0.11; Analysis 3.14 ).

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Comparison 3 SLT versus social support and stimulation, Outcome 14 Economic outcomes.

9. Follow‐up data

Three trials comparing SLT versus social support and stimulation also gathered follow‐up data: at six weeks in Woolf 2015ii and Woolf 2015iii ) and at three and six months in David 1982 . Of these trials, we present data relating to functional communication and expressive language below.

David 1982 used the FCP to compare a group who received conventional SLT with a group that received communication treatment by volunteers. There was no evidence of a difference between the groups at three and six months' follow‐up. Similarly, Woolf 2015ii and Woolf 2015iii measured functional communication using discourse measures and found no evidence of a difference between the groups six weeks after the intervention based on measures of substantive turns, content words, or nouns per turn during an unstructured conversation. On pooling FCP data at three months from David 1982 with data on content words per turn in Woolf 2015ii and Woolf 2015iii , there was no evidence of a difference between the groups. This did not change when we substituted other discourse data described above in the analysis ( Woolf 2015ii ; Woolf 2015iii ; see Analysis 5.1 ).

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Comparison 5 SLT versus social support and stimulation (follow‐up), Outcome 1 Functional communication.

2. Expressive language

Six weeks after the intervention, two trials measured participants' naming abilities using the Spoken Picture Naming Test ( Woolf 2015ii ; Woolf 2015iii ). Pooling this data, the individuals that received SLT were able to name more words than those that received social support (P = 0.03; SMD 2.25, 95% CI 0.18 to 4.32; Analysis 5.2 ).

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Comparison 5 SLT versus social support and stimulation (follow‐up), Outcome 2 Expressive language: single words (6 week follow‐up).

Comparisons: SLT A versus SLT B

A total of 1242 participants were included in 38 randomised comparisons of one SLT intervention (SLT A) with another SLT intervention (SLT B) ( B.A.Bar 2011ii ; Bakheit 2007 ; Crerar 1996 ; Crosson 2014 ; Denes 1996 ; Di Carlo 1980 ; Drummond 1981 ; FUATAC ; Hinckley 2001 ; Leal 1993 ; Lincoln 1982i ; Lincoln 1982ii ; Lincoln 1984b ; Meikle 1979 ; Meinzer 2007 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; ORLA 2006 ; ORLA 2010 ; Prins 1989 ; Pulvermuller 2001 ; RATS ; RATS‐2 ; SEMaFORE ; Sickert 2014 ; Shewan 1984i ; Smith 1981iii ; SP‐I‐RiT ; Varley 2016ii ; Van Steenbrugge 1981 ; VERSE I ; VERSE II ; Yao 2005iii ; Wertz 1981 ; Wertz 1986iii ; Wilssens 2015 ; Woolf 2015i ). As within other sections of this review, descriptions of the participants' age and other characteristics across trials varied ( Table 6 ).

Participants' age ranges, spanning 17 to 92 years, were available for 15 trials, while 22 trials reported mean ages ( B.A.Bar 2011ii ; Crosson 2014 ; Denes 1996 ; Drummond 1981 ; Hinckley 2001 ; Leal 1993 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; RATS ; RATS‐2 ; SEMaFORE ; Smith 1981iii ; Sickert 2014 ; SP‐I‐RiT ; Varley 2016i ; Varley 2016ii ; VERSE I ; VERSE II ; Wertz 1986iii ; Wilssens 2015 ; Woolf 2015i ), and one reported the number of participants within age bands ( Yao 2005iii ) ( Table 6 ).

All but four trials reported the length of time since their participants had experienced the onset of aphasia ( FUATAC ; SEMaFORE ; Smith 1981iii ; Yao 2005iii ). Mean time since onset varied from less than a week after stroke ( VERSE I ; VERSE II ), to within the first month ( Bakheit 2007 ; Leal 1993 ; Shewan 1984i ; Wertz 1981 ), two months ( Sickert 2014 ; SP‐I‐RiT ), three months ( MIT 2014i ; MIT 2014ii ), or even up to one year or more after stroke ( B.A.Bar 2011ii ; Crosson 2014 ; Drummond 1981 ; Hinckley 2001 ; Meinzer 2007 ; NARNIA 2013 ; ORLA 2006 ; ORLA 2010 ; Pulvermuller 2001 ; Prins 1989 ; Van Steenbrugge 1981 ; Varley 2016i ; Varley 2016ii ; Wilssens 2015 ; Woolf 2015i ) ( Table 6 ). Similarly, almost all trials reported the severity of aphasia, with only four failing to report how severe participants' aphasia was ( Drummond 1981 ; FUATAC ; SEMaFORE ; Yao 2005iii ). In most cases, trials reported the range of participants' aphasia severity using a suitable assessment tool, but in some cases this aspect was reported in more general terms ( Table 6 ). Some trials focused specifically on participants with moderate ( Wilssens 2015 ), severe ( Denes 1996 ; Di Carlo 1980 ; Lincoln 1984b ), or moderate to severe presentations of aphasia ( B.A.Bar 2011ii ; Lincoln 1982i ; Leal 1993 ).

Trials in this section compared one SLT approach to an alternative approach to SLT intervention, where the interventions differed in relation to the therapy regimen (intensity, dose, duration), delivery model (one‐to‐one or group therapy, volunteer or computer facilitated therapy), or theoretical underpinnings of the therapy delivered.

High‐intensity versus low‐intensity SLT

As prespecified, we looked at the data from eight trials which compared a high‐intensity SLT intervention with a low‐intensity SLT intervention ( Bakheit 2007 ; Denes 1996 ; FUATAC ; ORLA 2006 ; Pulvermuller 2001 ; Smith 1981iii ; SP‐I‐RiT ; VERSE I ). For participants in the high‐intensity groups, the number of hours weekly ranged from 4 hours ( Smith 1981iii ), 5 hours ( Bakheit 2007 ; Denes 1996 ), 7.5 hours ( VERSE I ), 10 hours ( ORLA 2006 ; Pulvermuller 2001 ; SP‐I‐RiT ), or 15 hours ( FUATAC ). In contrast the low‐intensity SLT groups received 1.5 hours ( Smith 1981iii ; VERSE I ), 2 hours ( Bakheit 2007 ; SP‐I‐RiT ), 3 hours ( Denes 1996 ), 4 hours ( FUATAC ; ORLA 2006 ), or 5 hours ( Pulvermuller 2001 ) weekly. The participants' time since stroke ranged from recruitment at an average of three days after stroke ( VERSE I ), approximately a month ( Bakheit 2007 ), two months ( Denes 1996 , SP‐I‐RiT ), up to three months ( FUATAC , unreported but estimated in Smith 1981iii ), and two years ( Pulvermuller 2001 low intensity group), three to four years ( ORLA 2006 ), and eight years ( Pulvermuller 2001 high‐intensity SLT group).

Statistical data for communication outcomes were only available for six trials ( Bakheit 2007 ; Denes 1996 ; ORLA 2006 ; Pulvermuller 2001 ; SP‐I‐RiT ; VERSE I ), and we made comparisons by measuring participants' functional communication, receptive language, expressive language, severity of impairment, psychosocial impact, number of dropouts, and adherence to allocated intervention. The trials did not report on economic outcome measures.

VERSE I and SP‐I‐RiT compared high versus low intensity interventions (both within a couple of months after stroke onset), measuring participants' functional communication using the FCP. VERSE I also used Discourse Analysis (DA) scores (informativeness and efficiency ( Nicholas 1995 )). On pooling the FCP data, the groups that received high‐intensity SLT had better functional communication than those that received low intensity SLT (P = 0.003; MD 11.75 95% CI 4.09 to 19.40; Analysis 4.1 ). When the VERSE I DA data were pooled with the SP‐I‐RiT FCP data, there was a similar finding (P = 0.002, SMD 0.69 95% CI 0.25 to 1.13).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 1 Functional communication.

Measures of participants' receptive language skills were available for Denes 1996 , SP‐I‐RiT and Pulvermuller 2001 . These trials measured participants' auditory comprehension using the Token Test, the Aachen Aphasia Test (AAT) and Lisbon Aphasia Assessment Batter comprehension subtests. On pooling the final value scores reported by Pulvermuller 2001 and SP‐I‐RiT from the Token Test, we observed significant heterogeneity (P = 0.03; I 2 = 79%) that could represent substantial heterogeneity ( Higgins 2011 ). However, there was no indication of a significant difference between comprehension skills in participants that had received high‐intensity SLT versus those that had received low‐intensity SLT ( Analysis 4.2 ). Denes 1996 only reported change‐from‐baseline scores, and thus they are not presented here.

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 2 Receptive language: auditory comprehension.

SP‐I‐RiT measured participants' reading abilities using the Portuguese version of the AAT and found no evidence of a difference between participants that received high‐intensity SLT and those that received low‐intensity SLT ( Analysis 4.3 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 3 Receptive language: reading comprehension.

Three trials compared the expressive language skills of participants that received a high‐intensity SLT with those that received a low‐intensity SLT intervention on naming, repetition, and writing tests ( Denes 1996 ; Pulvermuller 2001 ; SP‐I‐RiT ). Denes 1996 measured expressive language skills using the AAT nNaming, repetition and written subtests, but only the groups' change‐from‐baseline scores were available, so we do not present them here.

Pulvermuller 2001 and SP‐I‐RiT measured participants' naming skills using the AAT naming subtest and the Lisbon Aphasia Assessment Battery. There was no indication of a difference between the groups ( Analysis 4.4 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 4 Expressive language: naming.

Trialists compared the writing skills of participants that had received high‐ and low‐intensity SLT using the AAT ( Denes 1996 ; SP‐I‐RiT ). Only change‐from‐baseline data were available from Denes 1996 , so we do not present them here ( Analysis 4.5 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 5 Expressive language: written.

On pooling data from the repetition subtests of the AAT and the Lisbon Aphasia Assessment Battery ( Pulvermuller 2001 ; SP‐I‐RiT ), there was no evidence of a difference between the groups ( Analysis 4.6 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 6 Expressive language: repetition.

SP‐I‐RiT also captured the participants' fluency and found no evidence of a difference between the groups ( Analysis 4.7 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 7 Expressive language: fluency.

Seven trials compared participants' overall level of aphasia severity following interventions that varied in intensity by using the WAB ( Bakheit 2007 ; ORLA 2006 ; VERSE I ), the AAT ( Pulvermuller 2001 ), the BDAE ( SP‐I‐RiT ), the Lisbon Aphasia Assessment Battery ( SP‐I‐RiT ), and the MTDDA ( Smith 1981iii ). Suitable statistical data allowing inclusion in the meta‐analysis were unavailable from Smith 1981iii , and only change‐from‐baseline scores were available for the AAT, preventing inclusion in the meta‐analysis. On pooling the available final scores summary data (using the BDAE data from the SP‐I‐RiT trial), the groups that received high‐intensity SLT performed significantly better on measures of aphasia severity than those that received a low‐intensity SLT intervention (P = 0.02, SMD 0.38, 95% CI 0.07 to 0.69; Analysis 4.8 ). We did observe some non‐significant heterogeneity (P = 0.37; I 2 = 7%). We obtained a similar result when pooling the data for the Lisbon Aphasia Assessment Battery ( SP‐I‐RiT ) (P = 0.02; SMD 0.40 95% CI 0.07 to 0.74).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 8 Severity of impairment: Aphasia Battery Score.

Following Cochrane editorial review comments, we conducted a post hoc subgroup analysis that considered the trials' recruitment time point since aphasia onset. Data from trials delivering interventions to participants up to three months poststroke (a clinically relevant timeframe) continued to demonstrate benefit from intensive intervention (N = 157; P = 0.03; SMD 0.47 95% CI 0.05 to 0.88) in the presence of some non‐significant heterogeneity (P = 0.21; I 2 = 36%; Bakheit 2007 ; SP‐I‐RiT ; VERSE I ). Conversely, when we conducted the post hoc analyses on data from the subgroup of trials recruiting participants several years after stroke ( ORLA 2006 ; Pulvermuller 2001 ), there was no longer evidence of a difference between the small numbers of participants that received high‐intensity SLT (N = 16) versus low‐intensity SLT (N = 14). We will revisit this issue within the Discussion.

Smith 1981iii used the GHQ while SP‐I‐RiT used the Stroke Aphasia Depression Questionnaire to compare groups receiving high‐intensity and low‐intensity SLT. Appropriate summary data from Smith 1981iii were unavailable. Presenting data from SP‐I‐RiT , there was no evidence of a difference between the participants' experience of depression ( Analysis 4.9 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 9 Mood.

Data on participants that dropped out of trials included in this comparison were available for Bakheit 2007 , Denes 1996 , ORLA 2006 , Pulvermuller 2001 , SP‐I‐RiT and VERSE I and were partially available for Smith 1981iii . Smith 1981iii excluded five additional participants from the final analysis (three were found not to have aphasia and two died), but their group allocation was unclear. These five individuals were not included in this meta‐analysis. It was unclear whether any were lost in FUATAC . No participants appear to have been lost from the treatment or follow‐up time points in the Denes 1996 , ORLA 2006 , or Pulvermuller 2001 studies. Both ORLA 2006 and Pulvermuller 2001 recruited between an average of two and eight years after stroke.

Across the trials, significantly more participants (N = 35) were lost to the high‐intensity SLT intervention groups compared with those lost to low‐intensity SLT interventions (N = 17) (P = 0.01, OR 2.35, 95% CI 1.20 to 4.60) ( Analysis 4.10 ).

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 10 Number of dropouts for any reason.

Bakheit 2007 (in part), SP‐I‐RiT , and VERSE I reported the reasons for loss of participants from within the study. Of these, seven voluntarily withdrew from the high‐intensity SLT group during the treatment phase, while one withdrew from the low‐intensity group. There was no significant difference between the groups on this measure.

8. Follow‐up data (high‐intensity versus low‐intensity SLT)

Three trials comparing participants who received high‐intensity SLT versus low intensity SLT included a follow‐up data collection point after the intervention period in relation to: functional communication, receptive language, expressive language, severity of impairment, and number of dropouts ( Bakheit 2007 ; SP‐I‐RiT ; VERSE I ).

Functional communication

We collected follow‐up data on functional communication as measured by the FCP in SP‐I‐RiT and VERSE I by discourse analysis in VERSE I at 40 weeks ( SP‐I‐RiT ), six months ( VERSE I ), and 12 months postintervention ( SP‐I‐RiT ) ( Analysis 6.1 ). On pooling the FCP data, participants who had received high‐intensity SLT continued to perform significantly better on measures of functional communication than those who had received low‐intensity SLT (P = 0.02; SMD 0.53; 95% CI 0.07 to 0.99). Other measures did not demonstrate a significant difference between the groups.

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 1 Functional communication.

Receptive language

The SP‐I‐RiT trial captured auditory comprehension (LAAB and the Token Test) and reading comprehension (AAT subtest) at 40 weeks and 12 months postintervention. There was evidence of significantly better performance on measures of auditory comprehension by participants that had received the high‐intensity SLT compared with those that had received the low‐intensity SLT. These and other data are presented in Analysis 6.2 .

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 2 Receptive language.

Expressive language

Similarly, data on participants' expressive language skills were collected in the SP‐I‐RiT trial relating to their naming, writing to dictation, repetition, and fluency at 40 weeks and 12 months. There was evidence of a difference between participants' performance ( Analysis 6.3 ).

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 3 Expressive language.

Severity of impairment

Three trials followed up participants at three months ( Bakheit 2007 ), six months ( VERSE I ), and 40 weeks and 12 months ( SP‐I‐RiT ) to compare participants who had received high‐intensity SLT versus low‐intensity SLT on measures of aphasia severity including the WABAQ ( Bakheit 2007 ; VERSE I ), the BDAE ( SP‐I‐RiT ), and the LAAB–AQ ( SP‐I‐RiT ). On pooling the data (using the BDAE SP‐I‐RiT data only), there was no evidence of a difference between the groups (P = 0.07; SMD 0.37 95% CI −0.03 to 0.77) ( Analysis 6.4 ).

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 4 Severity of impairment: Aphasia Battery Score.

SP‐I‐RiT used the Stroke Aphasia Depression Questionnaire to compare those that received high‐ and low‐intensity SLT. There was no evidence of a difference between the groups at 40 weeks or 12 months follow‐up ( Analysis 6.5 ).

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 5 Mood.

Number of dropouts

Three trials reported the number of participants lost to follow‐up ( Bakheit 2007 ; Smith 1981iii ; SP‐I‐RiT ; VERSE I ) from the high‐intensity groups (N = 15) and the low‐intensity groups (N = 10). There was no evidence of a difference between the groups ( Analysis 6.6 )

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Comparison 6 High‐ versus low‐intensity SLT (follow‐up), Outcome 6 Number of dropouts for any reason.

High versus low dose SLT

As planned, we considered six trials that compared a high dose with a low dose SLT intervention as measured in hours of therapy provision. The number of therapy hours in the high dose SLT intervention varied from a total of 27 hours ( VERSE I ), 60 hours ( Bakheit 2007 ; ORLA 2006 ), 90 hours ( FUATAC ), 97 to 129 hours ( Denes 1996 ), and up to 208 hours ( ORLA 2006 ). Participants receiving a low dose SLT intervention received 5 hours ( VERSE I ), 23 hours ( FUATAC ; Smith 1981iii ), 24 hours ( Bakheit 2007 ; ORLA 2006 ), 69 hours ( Smith 1981iii ), or 78 hours ( Denes 1996 ). These high and low dose SLT groups were compared on measures of functional communication, receptive language, expressive language, severity of impairment, number of dropouts, and adherence to allocated intervention.

VERSE I measured participants' functional communication using the FCP and Discourse Analysis (DA) scores (informativeness and efficiency; Nicholas 1995 ). The participants that had received a high dose of SLT (up to 27 hours) had significantly better functional communication scores on both measures than those that received low dose (five hours) SLT ( Analysis 7.1 ).

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Comparison 7 High versus low dose SLT, Outcome 1 Functional communication.

Denes 1996 measured and compared participants' receptive language on the AAT Comprehension subtest and the Token Test. Only change‐from‐baseline data were available, which we present here ( Analysis 7.2 ). There was no evidence of a difference between the high and low dose SLT groups.

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Comparison 7 High versus low dose SLT, Outcome 2 Receptive language: auditory comprehension (change from baseline).

Similarly, Denes 1996 measured participants' expressive language on the AAT naming and repetition subtests. Only change‐from‐baseline data were available ( Analysis 7.3 ). There was no evidence of a difference between the high and low dose SLT groups. However, on measures of written language, the participants that received high dose of SLT performed significantly better than those that received a low dose of SLT ( Analysis 7.4 ).

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Comparison 7 High versus low dose SLT, Outcome 3 Expressive language: spoken (change from baseline).

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Comparison 7 High versus low dose SLT, Outcome 4 Expressive language: written (change from baseline).

Five trials compared participants' overall level of aphasia severity following a high and low dose of SLT using the WAB ( Bakheit 2007 ; ORLA 2006 ; VERSE I ), the AAT ( Denes 1996 ), and the MTDDA ( Smith 1981iii ). Suitable statistical data allowing inclusion in the meta‐analysis were unavailable from Smith 1981iii , and Denes 1996 only reported change‐from‐baseline data, which are not included in this meta‐analysis of final value scores. On pooling the data, there was no evidence of a difference in the participants that received a high or low dose of SLT on measures of aphasia severity ( Analysis 7.5 ), although we did observe some non‐significant heterogeneity (P = 0.14; I 2 = 49%).

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Comparison 7 High versus low dose SLT, Outcome 5 Severity of impairment: Aphasia Battery Score.

5. Number of dropouts

The numbers of participants that dropped out of trials in this comparison were available for Bakheit 2007 , Denes 1996 , ORLA 2006 and VERSE I and were partially available for Smith 1981iii . No participants appear to have been lost from the treatment or follow‐up time points in Denes 1996 or ORLA 2006 . It was unclear whether any were lost from FUATAC . Smith 1981iii excluded five additional participants (not included in this meta‐analysis) from the final analysis (three were found not to have aphasia and two died), but their group allocation was unclear. On pooling the data, significantly more participants (N = 99) were lost to the high dose SLT intervention groups versus the low dose SLT interventions (N = 87) (P = 0.03; OR 2.01 95% CI 1.07 to 3.79). There was no indication of heterogeneity. Of these participants, some were lost at follow‐up (eight from high dose and five from the low dose SLT groups) ( Bakheit 2007 ; VERSE I ; Analysis 7.6 ).

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Comparison 7 High versus low dose SLT, Outcome 6 Number of dropouts for any reason.

6. Adherence to allocated intervention

Two of the five trials reporting dropouts described the reasons for loss of participants from within the study. Six participants voluntarily withdrew from the high dose SLT groups during the treatment phase, while one withdrew from the low dose group. There was no evidence of a significant difference between the groups ( Analysis 7.7 ).

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Comparison 7 High versus low dose SLT, Outcome 7 Adherence to allocated intervention.

7. Follow‐up data (high dose versus low dose SLT)

Both Bakheit 2007 and VERSE I compared participants who received a high dose of SLT with those who received a low dose of SLT at follow‐up data collection points in relation to functional communication, severity of impairment, and number of dropouts.

VERSE I compared participants' functional language skills using the FCP and Discourse Analysis methods but found no evidence of a significant difference between the groups at follow‐up ( Analysis 8.1 ).

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Comparison 8 High versus low dose SLT (follow‐up), Outcome 1 Functional communication.

Similarly, using the WAB as a measure of aphasia severity, there was no evidence of a difference between the groups at follow‐up when pooling data from Bakheit 2007 and VERSE I ( Analysis 8.2 ).

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Comparison 8 High versus low dose SLT (follow‐up), Outcome 2 Severity of impairment: Aphasia Battery Score.

On pooling the follow‐up data across the three trials that reported dropouts ( Bakheit 2007 ; Smith 1981iii ; VERSE I ), there was no evidence of a difference between the groups that received a high dose of SLT and those that received a low dose ( Analysis 8.3 ).

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Comparison 8 High versus low dose SLT (follow‐up), Outcome 3 Number of dropouts for any reason.

Early versus delayed SLT

Four trials delivered an early SLT intervention and delayed the SLT intervention for the other group ( B.A.Bar 2011ii ; MIT 2014ii , Lyon 1997 ; Varley 2016ii ). While Lyon 1997 incorporated a delayed intervention, we could not include the data in this comparison; the data collection point was prior to the delayed intervention, and thus the trial data contributes to the SLT versus no SLT comparison. The remaining trials compared groups on measures of functional communication, receptive language, expressive language, severity of impairment, number of dropouts, and adherence to allocated intervention.

Both B.A.Bar 2011ii and MIT 2014i measured participants' functional communication using the ANELT. The data for MIT 2014i , however, were unavailable at the time of updating this review and could not be included here. Data from B.A.Bar 2011ii demonstrate no evidence of a difference between the group that received early SLT versus SLT later after aphasia onset. Findings were similar on follow‐up of the participants four weeks later ( Analysis 9.1 ).

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Comparison 9 Early versus delayed SLT, Outcome 1 Functional communication.

B.A.Bar 2011ii compared participants' auditory comprehension skills using the Token Test but found no evidence of a difference between the groups that received early SLT versus delayed SLT ( Analysis 9.2 ).

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Comparison 9 Early versus delayed SLT, Outcome 2 Receptive language: auditory comprehension.

Similarly, participants' expressive language skills were captured using measures of naming ( B.A.Bar 2011ii ; Varley 2016ii ), writing ( B.A.Bar 2011ii ), repetition ( B.A.Bar 2011ii ; Varley 2016ii ) and word fluency (food and animal words) ( B.A.Bar 2011ii ). Investigators measured outcomes immediately after the intervention and one month later in B.A.Bar 2011ii or two months later in Varley 2016ii . There was no evidence of a difference between the groups on any of these measures or at these time points. We only present the naming (matched) and repetition (matched) data in these meta‐analyses ( Analysis 9.3 to Analysis 9.6 ). Pooling using the treated or control items from Varley 2016ii data did not alter this finding. We do not present these data here.

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Comparison 9 Early versus delayed SLT, Outcome 3 Expressive language: naming.

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Comparison 9 Early versus delayed SLT, Outcome 6 Expressive language: fluency.

The participants' performance on the AAT overall demonstrated no evidence of a difference between the severity of their aphasia ( Analysis 9.7 ).

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Comparison 9 Early versus delayed SLT, Outcome 7 Severity of impairment.

MIT 2014i and Varley 2016ii reported dropouts, with six participants leaving the early SLT group and two leaving the delayed SLT group. There was no evidence of a difference between the groups ( Analysis 9.8 ). B.A.Bar 2011ii did not report any dropouts.

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Comparison 9 Early versus delayed SLT, Outcome 8 Number of dropouts for any reason.

6. Follow‐up data (8 weeks)

Varley 2016ii followed up participants eight weeks after the delayed treatment and measured expressive language (naming and repetition) across treated, matched and control items. There was no evidence of a difference between the groups ( Analysis 10.1 ; Analysis 10.2) . Similarly there was no evidence of a difference in the number of participants dropping out form the early SLT intervention versus the delayed SLT group ( Analysis 10.3 ).

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Comparison 10 Early versus delayed SLT (follow‐up), Outcome 1 Expressive language: naming.

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Comparison 10 Early versus delayed SLT (follow‐up), Outcome 2 Expressive language: repetition.

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Comparison 10 Early versus delayed SLT (follow‐up), Outcome 3 Number of dropouts for any reason.

SLT: short versus long duration

Five trials compared therapy of a long and short duration as measured by the weeks or months over which the SLT intervention was delivered. Examples of short SLT interventions lasted 2 weeks ( Pulvermuller 2001 ), 10 weeks ( SP‐I‐RiT ), or they had a mean duration of 11.4 weeks ( ORLA 2010 ), 20.8 weeks ( Meikle 1979 ), or they lasted between 6 and 9 months ( Di Carlo 1980 ). These were compared with therapy delivered over a longer period of time, ranging from 3 to 5 weeks ( Pulvermuller 2001 ), a mean of 13.31 weeks ( ORLA 2010 ), 37.13 weeks ( Meikle 1979 ), 50 weeks ( SP‐I‐RiT ), or between 5 and 22 months ( Di Carlo 1980 ). Groups were compared on measures of functional communication, receptive language, expressive language, mood, severity of impairment, and number of dropouts and adherence to allocated intervention ( Analysis 11.1 to Analysis 11.16 ).

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Comparison 11 SLT of short versus long duration, Outcome 1 Functional communication.

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Comparison 11 SLT of short versus long duration, Outcome 16 Adherence to allocated intervention.

Two trials compared participants' functional communication using measures of discourse or the Functional Communication Profile ( ORLA 2010 ; SP‐I‐RiT ). Pooling the data demonstrated that those individuals that had received SLT over a longer period of time performed significantly better on measures of functional communication than those who had received therapy over a short period of time (P = 0.002, SMD 0.81, CI 95% 0.23 to 1.40; ( Analysis 11.1 ). This finding was no longer evident at 50 weeks and one year follow‐up during the SP‐I‐RiT trial ( Analysis 11.2 ).

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Comparison 11 SLT of short versus long duration, Outcome 2 Functional communication (follow‐up).

Two trials measured participants' auditory comprehension ( Pulvermuller 2001 ; SP‐I‐RiT ), and three assessed written language comprehension ( Di Carlo 1980 ; ORLA 2010 ; SP‐I‐RiT ). Trials evaluating auditory comprehension used the AAT comprehension subtest ( Pulvermuller 2001 ), the Token Test ( Pulvermuller 2001 ), and the Lisbon Aphasia Assessment Battery ( SP‐I‐RiT ). On pooling the AAT data with the LAAB data, there was a significant difference between the groups: participants who received therapy over a long period of time scored significantly higher on auditory comprehension tests than those who received SLT over a short period of time (P = 0.01, SMD 0.81, CI 95% 0.17 to 1.45 and low heterogeneity: I 2 = 0%). However, on pooling the Token Test data with the LAAB data, we observed significant heterogeneity (I 2 = 69%) and no evidence of a difference between the groups' auditory comprehension (SMD 0.49 CI 95% −0.67 to 1.65). We present the AAT data in Analysis 11.3 . There was no evidence of this extending to follow‐up data collected at 50 or 62 weeks ( Analysis 11.4 ; Analysis 11.5 ).

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Comparison 11 SLT of short versus long duration, Outcome 3 Receptive language: auditory comprehension.

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Comparison 11 SLT of short versus long duration, Outcome 4 Receptive language: comprehension (50 week follow‐up).

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Comparison 11 SLT of short versus long duration, Outcome 5 Receptive language: comprehension (62 week follow‐up).

After pooling data from across three trials, participants' ability to read did not differ between groups ( ORLA 2010 , SP‐I‐RiT , Di Carlo 1980 ; Analysis 11.6 ).

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Comparison 11 SLT of short versus long duration, Outcome 6 Receptive language: reading comprehension.

Three trials found no evidence of a difference between the groups' naming abilities when using the AAT naming subtest ( Pulvermuller 2001 ), the Lisbon Aphasia Assessment Battery ( SP‐I‐RiT ), or the Thorndike Lorge Word List by Thorndike 1944 ( Di Carlo 1980 ) ( Analysis 11.7 ). Similarly, there was no evidence of a difference between groups in writing abilities ( Analysis 11.8 ) or repetition ( Analysis 11.9 ). One small trial found that the group that received an SLT intervention for a longer period performed significantly better on measures of word fluency ( SP‐I‐RiT ; Analysis 11.10 ). Based on data from the same trial, there was no evidence of a difference between the groups at 50 or 62 weeks' follow‐up ( Analysis 11.11 ).

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Comparison 11 SLT of short versus long duration, Outcome 7 Expressive language: naming.

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Comparison 11 SLT of short versus long duration, Outcome 8 Expressive language: written.

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Comparison 11 SLT of short versus long duration, Outcome 9 Expressive language: repetition.

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Comparison 11 SLT of short versus long duration, Outcome 10 Expressive language: fluency.

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Comparison 11 SLT of short versus long duration, Outcome 11 Expressive language: 50 and 62 weeks follow‐up.

SP‐I‐RiT also compared participants using the Stroke Aphasia Depression Questoinnaire following SLT of a long or short duration immediately after treatment and at 50 and 62 weeks' follow‐up. There was no evidence of a difference between the groups ( Analysis 11.12 ).

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Comparison 11 SLT of short versus long duration, Outcome 12 Depression.

Four trials measured aphasia severity and compared participants who had received SLT over a long and short period of time. After pooling data from the WABAQ ( ORLA 2010 ), the PICA ( Meikle 1979 ), the AAT ( Pulvermuller 2001 ), and the BDAE ( SP‐I‐RiT ), there was no evidence of a difference between the groups ( Analysis 11.13 ). SP‐I‐RiT also gathered data on severity using the LIsbon Aphasia Assessment Battery Aphasia Quotient, but pooling this data instead of the BDAE did not alter the finding. At follow‐up, there was little indication of a difference between the groups ‐ no differences were observed on measures using the LAAB, while at one year the group that received a long period of SLT performed significantly better on the BDAE than those who had received SLT over a short period of time ( Analysis 11.14 ).

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Comparison 11 SLT of short versus long duration, Outcome 13 Severity of impairment: Aphasia Battery Score.

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Comparison 11 SLT of short versus long duration, Outcome 14 Severity of impairment: Aphasia Battery Score (follow‐up).

6. Number of dropouts and adherence to allocated intervention

Only Meikle 1979 reported any dropouts in this comparison, and there was no evidence of a difference between the groups ( Analysis 11.15 ) or in relation to adherence to the allocated intervention ( Analysis 11.16 ).

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Comparison 11 SLT of short versus long duration, Outcome 15 Number of dropouts for any reason.

Group versus one‐to‐one SLT

Six trials compared a group‐based SLT intervention with conventional one‐to‐one SLT ( FUATAC ; Pulvermuller 2001 ; VERSE II ; Wertz 1981 ; Wilssens 2015 ; Yao 2005iii ). Within the group SLT interventions, participants received SLT in groups of 2 to 3 ( FUATAC ), 3 ( Pulvermuller 2001 ), 2 to 4 ( VERSE II ), 5 ( Wilssens 2015 ), between 3 to 7 ( Wertz 1981 ), and 10 ( Yao 2005iii ). Several group SLT interventions used a constraint‐induced aphasia therapy approach ( FUATAC ; Pulvermuller 2001 ; VERSE II ; Wilssens 2015 ) (only verbal responses were allowed). In contrast, other group interventions encouraged group discussion and recreational activities with a therapist ( Wertz 1981 ), or they focused on 'collective language strengthening training' ( Yao 2005iii ).

Participants receiving the one‐to‐one SLT intervention received a semantic therapy in Visch‐Brink 2001 and Wilssens 2015 or conventional SLT in FUATAC , Pulvermuller 2001 , VERSE II , Wertz 1981 and Yao 2005iii . Investigators made between‐intervention comparisons on a variety of measures: functional communication, receptive language, expressive language, quality of life, severity of impairment, number of dropouts, and adherence to allocated intervention. Studies did not measure psychosocial impact or economic measures.

Two trials measured change in functional communication using the CAL ( Pulvermuller 2001 ), the Conversational Rating Scale (CRS) ( Wertz 1981 ), and the Informants Rating of Functional Language (adapted form of the FCP) ( Wertz 1981 ). However, suitable statistical data were unavailable from these measures, and so we could not include them within the review. A later study took a subset of data from the Wertz 1981 trial and evaluated functional communication using the Pragmatic Protocol. In addition, we pooled data from Wilssens 2015 based on the ANELT with data from VERSE II on the percentage of content information units per minute in a sample of discourse. There was no evidence of a difference between the groups' performance on measures of functional communication ( Analysis 12.1 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 1 Functional communication.

Receptive language: auditory comprehension

Three trials measured participants' receptive language skills using the Token Test ( Pulvermuller 2001 ; Wertz 1981 ; Wilssens 2015 ), and two used the language comprehension subtest of the AAT ( Pulvermuller 2001 ; Wilssens 2015 ). Wertz 1981 reported mean values, but the SD values were unavailable. To facilitate inclusion of these data within the review, we imputed the SD value (13.93) from the Lincoln 1982 Token Test summary data. The reason for choosing this value was that both Wertz 1981 and Lincoln 1982 used the same form of the Token Test and used it to measure the language skills of similar participant groups. On pooling these data, there was no evidence of a difference between the groups' auditory comprehension skills as measured by either comprehension subtest ( Pulvermuller 2001 ; see Analysis 12.2 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 2 Receptive language: auditory comprehension.

Receptive language: other

Wertz 1981 used the PICA Gestural subtest to compare participants that had received group SLT and those that had received one‐to‐one SLT. Though the mean values were available to the review, the SD values were unavailable. We identified and imputed an SD value of 25.67 from Wertz 1986 , where the highest of three possible values in this trial from relevant clinical groups was chosen to facilitate inclusion of the study within the review. There was no evidence of a difference between the groups ( Analysis 12.3 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 3 Receptive language: other.

Expressive language: spoken

Participants' expressive language skills were compared using the naming subtest of the AAT ( Pulvermuller 2001 ; Wilssens 2015 ), the Boston Naming Test ( Wilssens 2015 ), measures of word fluency, repetition, and the PICA verbal subtest. On pooling the AAT naming data, there was no evidence of a difference between the groups' expressive language skills ( Analysis 12.4 ). This did not change when using the BNT data from Wilssens 2015 ) in the meta‐analysis in place of the AAT subtest data from the same trial (P = 0.58; SMD 0.22 95% CI −0.56 to 1.00).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 4 Expressive language: naming.

Wertz 1981 used the verbal subtest of the PICA to measure participants' language expression. The mean scores of participants who received group SLT and those that received one‐to‐one SLT were available, but SD data were not. We identified and imputed an SD value (20.01) from Wertz 1986 , choosing the highest of three possible values in this trial from relevant clinical groups to facilitate inclusion of the study within the review. There was no evidence of a difference between the groups ( Analysis 12.5 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 5 Expressive language: general.

Wertz 1981 used measures of word fluency to compare participants' word‐finding skills. Authors reported mean values for the participants receiving group SLT and those receiving one‐to‐one SLT, but not the SDs, so we could not include these results in the review.

Both Pulvermuller 2001 and Wilssens 2015 measured participants' repetition abilities using the AAT repetition subtest. They found no evidence of a difference between the participants who had received group SLT and those that received one‐to‐one SLT ( Analysis 12.6 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 6 Expressive language: repetition.

Wertz 1981 captured participants' written language skills using the graphic subtest of the PICA, and Wilssens 2015 used the AAT subtest. Authors reported mean values for participants who received group SLT and those who received one‐to‐one SLT, but SDs were unavailable. As with the other PICA data from Wertz 1981 , we identified and imputed an SD value (21.74) from Wertz 1986 , choosing the highest of three possible values in this trial from relevant clinical groups to facilitate inclusion of the study within the review. There was no evidence of a difference between participants' written language skills ( Analysis 12.7 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 7 Expressive language: written.

4. Quality of life

Of the trials in this section, only VERSE II measured participants' quality of life. Using the Stroke and Aphasia Quality of Life scale (SAQoL), the authors found no evidence of a difference between those that received group therapy and those that received one‐to‐one SLT ( Analysis 12.8 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 8 Quality of life.

Four trials measured the severity of participants' aphasia following one‐to‐one versus group SLT interventions using the CRRCAE AQ ( Yao 2005iii ), the PICA ( Wertz 1981 ), the AAT ( Pulvermuller 2001 ), and the WABAQ ( VERSE II ). Although the mean values for Wertz 1981 trial were available, the SD data were missing. We imputed an SD value (24.64) from Wertz 1986 to facilitate inclusion of the data within the review. On pooling the data from all four trials, there was no evidence of a difference between the scores of participants that received group SLT and those that received one‐to‐one SLT on this measure ( Analysis 12.9 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 9 Severity of impairment: Aphasia Battery Score.

Information on the number of participants leaving during the trials were available for most trials ( Pulvermuller 2001 ; VERSE II ; Wertz 1981 ; Wilssens 2015 ; Yao 2005iii ). Numbers of participants remaining in the trial were unclear for FUATAC . Three trials had no dropouts ( Pulvermuller 2001 ; Wilssens 2015 ; Yao 2005iii ). In contrast, almost half of those randomised in Wertz 1981 failed to remain in the study (33 dropouts); when we pooled these results with the data from VERSE II , there was no evidence of a difference in the numbers lost, with 25 leaving the group interventions and 20 leaving the one‐to‐one interventions ( Analysis 12.10 ).

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Comparison 12 Group versus one‐to‐one SLT, Outcome 10 Number of dropouts for any reason.

Wertz 1981 reported that 22 participants returned home or declined to travel to receive the allocated treatment intervention (see Table 7 ), but further details on the exact number of participants declining the interventions or how these numbers were split across intervention groups were unavailable. Similarly, while we know that three participants dropped out of the VERSE II trial, the reasons are unclear.

8. Follow‐up data (group versus one‐to‐one SLT)

Two trials continued to follow up participants who had received SLT in group or one‐to‐one sessions ( VERSE II ; Yao 2005iii ), measuring functional communication, severity of aphasia, quality of life, and number of dropouts during the follow‐up period.

VERSE II assessed functional communication, measuring the percentage of content units per minute in the discourse analysis samples at 12 weeks' and 26 weeks' follow‐up. There was no evidence of a difference between the groups ( Analysis 13.1 ).

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Comparison 13 Group versus one‐to‐one SLT (follow‐up), Outcome 1 Functional communication.

Severity of aphasia

VERSE II used the WABAQ to evaluate the severity of participants' aphasia, while Yao 2005iii used the CRRCAE AQ. On pooling the three‐month follow‐up data, there was no evidence of a difference between the groups ( VERSE II ; Yao 2005iii ; and is presented in Analysis 13.2 ). Pooling the WABAQ 26‐week data with the CRRCAE AQ data, showed that the participants that had received group therapy performed significantly better on measures of aphasia severity than those who had received one‐to‐one therapy (P = 0.03, SMD 0.82, 95% CI 0.06 to 1.58).

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Comparison 13 Group versus one‐to‐one SLT (follow‐up), Outcome 2 Severity of impairment: Aphasia Battery Score.

Quality of life

Similarly, VERSE II measured quality of life using the SAQoL at 12 and 26 weeks and found no evidence of a difference between the groups at either time point ( Analysis 13.3 ).

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Comparison 13 Group versus one‐to‐one SLT (follow‐up), Outcome 3 Quality of life.

Only VERSE II reported the number of dropouts at follow‐up points. There was no evidence of a difference between the groups ( Analysis 13.4 ).

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Comparison 13 Group versus one‐to‐one SLT (follow‐up), Outcome 4 Number of dropouts for any reason.

Volunteer‐facilitated SLT versus professionally facilitated SLT

Four trials compared participants who received volunteer‐facilitated SLT versus SLT provided directly by a professional therapist ( Leal 1993 ; Meikle 1979 ; Meinzer 2007 ; Wertz 1986iii ). In most cases a speech and language therapist delivered the professional SLT ( Leal 1993 ; Meikle 1979 ; Wertz 1986iii ), although a specialist psychologist delivered the constraint‐induced SLT intervention in Meinzer 2007 . We believed that this trial was suitable for inclusion in this comparison, as it compared interventions delivered by a professional clinician with delivery facilitated by a trained volunteer.

Most volunteers were family members ( Leal 1993 ; Meinzer 2007 ; Wertz 1986iii ), although some trialists also engaged friends or recruited volunteers unknown to the participants ( Meikle 1979 ; Wertz 1986iii ). Volunteer groups across the trials all received SLT training, information on their patient's communication impairment, access to working materials or equipment, and ongoing support or supervision. Most studies indicated that the professional therapist was accountable for, or informed the design and content of, the volunteer‐facilitated SLT ( Meikle 1979 ; Meinzer 2007 ; Wertz 1986iii ).

The professional therapists intervened in a formal or clinical setting ( Leal 1993 ; Meikle 1979 ; Meinzer 2007 ; Wertz 1986iii ). The duration of the professional SLT interventions varied from three hours daily for 10 consecutive days in Meinzer 2007 , up to three hours weekly for six months in Leal 1993 , four hours weekly for an average of nine months (SD 22 weeks) in Meikle 1979 , or 10 hours weekly for approximately three months in Wertz 1986iii ). The duration of volunteer‐facilitated SLT and professionally delivered SLT was the same for two trials ( Meinzer 2007 ; Wertz 1986iii ). The volunteers in Meikle 1979 visited participants four times weekly over a shorter period of time (average of five months, SD 13.5 weeks), while the duration of the volunteer‐facilitated SLT in Leal 1993 is unclear. The four trials used a range of measures to compare volunteer‐facilitated SLT with professional SLT delivery including functional communication, receptive language, expressive language, severity of impairment, number of dropouts, and adherence to allocation.The studies did not compare psychosocial or economic measures.

Only Wertz 1986iii formally measured the functional communication skills of the participants that received volunteer‐facilitated SLT or professional SLT using the CADL and the FCP. There was no evidence of a difference between the groups ( Analysis 14.1 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 1 Functional communication.

Three trials evaluated participants' language comprehension abilities using the Token Test ( Leal 1993 ; Meinzer 2007 ; Wertz 1986iii ), but suitable statistical data were unavailable for Leal 1993 . Meinzer 2007 and Wertz 1986iii used the Token Test to measure differences in the auditory comprehension of participants that received volunteer‐facilitated SLT and those that received professional therapy input. There was no significant difference between the two groups' auditory comprehension ( Analysis 14.2 ). The comprehension subtest of the AAT measures both auditory and reading comprehension and was used by Meinzer 2007 to compare a group receiving volunteer‐facilitated SLT or SLT delivered by experienced professionals. There was no evidence of a difference between the groups' comprehension on these measures ( Analysis 14.2 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 2 Receptive language: auditory comprehension.

Receptive language: reading comprehension

Wertz 1986iii measured participants' reading comprehension using the RCBA. There was no evidence of a difference between the groups. Data from the AAT that Meinzer 2007 used to measure both auditory and reading comprehension are also presented (but not pooled) in this section ( Analysis 14.3 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 3 Receptive language: reading comprehension.

Wertz 1986iii compared participants' receptive language skills using the PICA gestural subtest. There was no evidence of a difference between the groups ( Analysis 14.4 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 4 Receptive language: other.

Meinzer 2007 measured expressive language skills using the naming subtest of the AAT, while Wertz 1986iii used the PICA verbal subtest to compare participants that received volunteer‐facilitated SLT and those that received professional SLT. There was no evidence of a difference between the groups ( Analysis 14.5 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 5 Expressive language: spoken.

The group that received the volunteer‐facilitated SLT intervention in Meinzer 2007 scored significantly higher on the repetition subtest (AAT) than those that received SLT from a professional therapist (P = 0.05, MD 13.50, 95% CI 0.19 to 26.81) ( Analysis 14.6 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 6 Expressive language: repetition.

The written language subtest of the AAT measures reading aloud and writing to dictation. Meinzer 2007 compared the groups that received volunteer‐facilitated SLT versus professionally delivered SLT using this measure. Similarly, Wertz 1986iii used the PICA graphic subtest to compare the groups. They found no evidence of a difference ( Analysis 14.7 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 7 Expressive language: written.

Four trials compared the two groups using measures of overall severity of aphasia following either volunteer‐facilitated SLT or professional SLT using the PICA ( Meikle 1979 ; Wertz 1986iii ), an AQ ( Leal 1993 ), and the AAT profile ( Meinzer 2007 ). Summary data from the groups' performance was unavailable for Leal 1993 , preventing inclusion within the review. There was no evidence of a difference between the two groups following pooling of data from the PICA and AAT profile ( Analysis 14.8 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 8 Severity of impairment: Aphasia Battery Score.

All four trials reported the number of participants that were lost to the trial following randomisation. Three trials lost a total of 30 participants from the groups receiving volunteer‐facilitated SLT, while 22 participants dropped out of the groups that received professional SLT interventions ( Leal 1993 ; Meikle 1979 ; Wertz 1986iii ). Meinzer 2007 had no participant withdrawals. An additional participant that had received volunteer‐facilitated SLT and two participants that had received professional SLT were lost at follow‐up ( Wertz 1986iii ). No participants were reported lost at follow‐up from Leal 1993 . Overall, there was no evidence of a difference in the numbers of dropouts between the groups that received volunteer‐facilitated SLT and those that had professionally delivered SLT ( Analysis 14.9 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 9 Number of dropouts for any reason.

Only two of the three trials provided details for participant withdrawals ( Leal 1993 ; Meikle 1979 ). Overall there was no difference between the groups. Five participants declined to continue participating in the volunteer‐facilitated SLT groups, while four declined in the professional SLT groups ( Analysis 14.10 ).

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Comparison 14 Volunteer‐facilitated versus professional SLT, Outcome 10 Adherence to allocated intervention.

Computer‐facilitated versus professionally facilitated SLT

Three trials compared an SLT intervention that was facilitated by a computer versus SLT that relied only on professional therapist support ( ORLA 2010 , Woolf 2015i , Wertz 1981 ). In ORLA 2010 all 25 participants received 24 one‐hour sessions of an Oral Reading for Language in Aphasia (ORLA) treatment. The rate of delivery of therapy ranged from one to four sessions per week per participant, with a mean overall treatment duration of 12.26 weeks (range 6 to 22 weeks). The dosage of therapy was similar across the comparison groups randomised within Wertz 1981 (352 hours) and Woolf 2015i (8 hours). Similarly, the groups within the trials did not differ in the number of weeks of treatment received. The trial compared computer‐facilitated SLT with professional SLT delivery across a range of measures, including functional communication, receptive language, expressive language, severity of impairment, number of dropouts, and follow‐up data. Studies did not evaluate psychosocial or economic measures.

ORLA 2010 reported two measures of discourse efficiency based on a picture description and narrative discourse samples (words per minute and content information units per minute; Nicholas 1995 ). Woolf 2015i also captured discourse measures (substantive turns, content words per turn and nouns per turn) based on an unstructured conversational sample. On pooling the content information data from both Woolf 2015i and ORLA 2010 with the Wertz 1981 Pragmatic Protocol data, there was no indication of a difference between the two groups' functional communication ( Analysis 15.1 ), nor did this finding alter on pooling the Wertz 1981 data with the other discourse summary data.

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 1 Functional communication.

Investigators compared participants' auditory and reading comprehension using the Token Test ( Wertz 1981 ), the PICA gestural subtest ( Wertz 1981 ), and the WAB reading comprehension subtest ( ORLA 2010 ). There was no indication of a difference between the groups that received SLT facilitated by computer and those that received SLT via a professional therapist on these receptive language measures ( Analysis 15.2 ).

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 2 Receptive language.

Both Wertz 1981 (PICA verbal subtest) and Woolf 2015i (picture naming test with score for treated, untreated and total) used measures of expressive language to compare trial groups. Participants who used a computer during therapy performed better on measures of untreated words than the participants who worked directly with a professional therapist. There was no other evidence of a difference between the groups ( Analysis 15.3 ). ORLA 2010 assessed participants' writing skills using the WAB writing subtest, and Wertz 1981 used the PICA graphic subtest. There was no evidence of a difference between the two groups' writing skills ( Analysis 15.4 ).

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 3 Expressive language.

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 4 Expressive language: written.

On pooling the data from ORLA 2010 (WABAQ) and the PICA overall ( Wertz 1981 ), there was no evidence of a significant difference between the participants that accessed SLT via a computer interface and those that had accessed it via a professional therapist ( Analysis 15.5 ).

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 5 Severity of impairment.

None of the participants in ORLA 2010 were lost during the study. While Wertz 1981 lost participants in both the group with access to a computer during therapy (N=15) and the group that had a professional therapist to support their therapy (N=16), there was no evidence of a difference between the number of dropouts between these groups ( Analysis 15.6 ).

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Comparison 15 Computer‐mediated versus professional SLT, Outcome 6 Number of dropouts for any reason.

6. Follow‐up data

Woolf 2015i followed participants up at six weeks and found no evidence of a difference between the groups accessing therapy via computer and those via a professional therapist as measured by the substantive turns, content words per turn, or the number of nouns per turn in an unstructured conversational sample ( Analysis 16.1 ).

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Comparison 16 Computer‐mediated versus professional SLT (follow‐up), Outcome 1 Functional communication (6 weeks).

Similarly, Woolf 2015i measured participants' expressive language skills at six weeks' follow‐up looking at treated and untreated Spoken Picture Naming items. They found no evidence of a difference in total Spoken Picture Naming treated items from the test. The participants who had access to computer‐facilitated SLT named more of the untreated items than the participants who had the support of a professional therapist face‐to‐face ( Analysis 16.2 ).

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Comparison 16 Computer‐mediated versus professional SLT (follow‐up), Outcome 2 Expressive language: naming (6 weeks).

Semantic SLT versus other approaches to SLT

Four trials compared participants that received SLT interventions based on a semantic therapeutic approach with those that received phonologically based SLT ( RATS ), communicative SLT ( RATS‐2 ), a repetition in the presence of a picture approach SLT ( SEMaFORE ), or CIAT approach to SLT ( Wilssens 2015 ). In the RATS‐2 semantic SLT intervention, participants in this arm could also have received a phonologically based SLT in conjunction with or instead of the semantic approach depending on the individual participant's needs. Therapy regimen was similar across both groups, with the semantic intervention being delivered over 9 to 10 days ( Wilssens 2015 ), six weeks ( SEMaFORE ), up to six months ( RATS‐2 ), or 40 weeks ( RATS ). Regardless of whether they were randomised to receive a semantically based SLT approach or another type of SLT, participants received 13.5 hours ( SEMaFORE ), an average of 19 hours ( Wilssens 2015 ), 40 to 60 hours ( RATS ), or 52 hours of SLT ( RATS‐2 ). Studies compared groups across a range of measures, including functional communication, receptive language, expressive language, number of dropouts, and adherence to allocated intervention. The trials did not assess psychosocial or economic measures. The SEMaFORE trial, although complete, was not yet fully published, so no suitable data were available for inclusion in the meta‐analyses in this section.

Three trials measured functional communication using the ANELT ( RATS ; RATS‐2 ; Wilssens 2015 ), and one used the CETI ( Wilssens 2015 ). On pooling the ANELT data, there was no evidence of a difference between the functional communication of groups that received a semantic SLT approach compared with those that received another SLT approach ( Analysis 17.1 ). There was no change in this finding upon pooling the Wilssens 2015 CETI data with the ANELT data from RATS and RATS‐2 .

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Comparison 17 Semantic SLT versus other SLT, Outcome 1 Functional communication.

Both RATS‐2 and Wilssens 2015 measured participants' auditory comprehension using the Token Test, and on pooling the data, there was no evidence of a difference between the groups ( Analysis 17.2 ). Wilssens 2015 also used the AAT comprehension test but found no difference between the groups' comprehension skills ( Analysis 17.2 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 2 Receptive language: auditory comprehension.

Three trials compared participants' language skills using the Semantic Association Test ( RATS ; RATS‐2 ; Wilssens 2015 ). On pooling the data there was no evidence of a difference between the groups that received semantic‐based SLT and those that received another SLT approach. Similarly, on the PALPA measures of Semantic Association ( RATS‐2 ; Wilssens 2015 ), the Auditory Lexical Decision ( RATS ; RATS‐2 ; Wilssens 2015 ), or the Auditory Synonym Judgement test ( Wilssens 2015 ), there was no evidence of a difference between the groups' performance ( Analysis 17.3 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 3 Receptive language: other.

Expressing language: naming

Wilssens 2015 compared participants' naming abilities using the AAT naming subtest and the BNT ( Analysis 17.4 ). There was no evidence of a difference between the groups.

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Comparison 17 Semantic SLT versus other SLT, Outcome 4 Expressive language: naming.

Expressing language: writing

Similarly, Wilssens 2015 used the AAT writing subtest to compare participants' writing skills and found no evidence of a difference between the groups ( Analysis 17.5 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 5 Expressive language: written.

Expressing language: repetition

Two trials compared participants' repetition skills using the PALPA non‐word repetition test ( RATS‐2 ; Wilssens 2015 ), and one used the AAT repetition subtest ( Wilssens 2015 ). There was no indication of a difference between the groups ( Analysis 17.6 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 6 Expressive language: repetition.

Expressing language: fluency

RATS‐2 measured participants' word fluency using letters and semantic subtests but found no evidence of a difference between the groups ( Analysis 17.7 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 7 Expressive language: fluency.

4. Number of dropouts

Wilssens 2015 had no dropouts during the course of the trial. In contrast, between RATS and RATS‐2 , 10 participants were lost from the semantic SLT interventions compared with 12 from the other SLT interventions ( Analysis 17.8 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 8 Number of dropouts for any reason.

5. Adherence to allocated intervention

Of the trials that reported dropouts, eight participants were unable to comply with the allocated semantic SLT intervention compared with eight from the phonological SLT and communicative SLT groups ( RATS ; RATS‐2 ; see Analysis 17.9 ).

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Comparison 17 Semantic SLT versus other SLT, Outcome 9 Adherence to allocated intervention.

Constraint‐induced aphasia therapy versus other SLT

Five trials have recently emerged comparing a CIAT SLT approach with either conventional one‐to‐one SLT ( FUATAC ; Pulvermuller 2001 ; VERSE II ), another group therapy ( Sickert 2014 ), or a semantic SLT approach ( Wilssens 2015 ). The CIAT was delivered over 10 days ( Pulvermuller 2001 ; Wilssens 2015 ), 15 days ( Sickert 2014 ), five weeks ( VERSE II ), and six weeks ( FUATAC ). The comparator SLT approach was delivered over 15 to 20 hours ( VERSE II ), 19 hours ( Wilssens 2015 ), 22.5 hours ( FUATAC ), 30 hours ( Sickert 2014 ), or an average of 34 hours ( Pulvermuller 2001 ). The duration of the contrasting therapy provision ranged from 9 to 10 days ( Wilssens 2015 ), 15 days ( Sickert 2014 ), three to five weeks ( Pulvermuller 2001 ), five weeks ( VERSE II ), and six weeks ( FUATAC ). Three trials controlled the duration and dose of therapy across both groups ( Sickert 2014 ; VERSE II ; Wilssens 2015 ).

Three trials compared participants that received CIAT to those that received another SLT approach on measures of functional communication, including the ANELT ( Wilssens 2015 ), Discourse Analysis (correct information numbers per minute during samples of picture description and procedural discourse) ( VERSE II ), the spontaneous speech AAT subtest ( Sickert 2014 ), and the CETI ( Wilssens 2015 ). On pooling the ANELT, Discourse Analaysis scores, and the AAT subtest data, there was no evidence of a difference between the groups ( Analysis 18.1 ). This finding did not change when the CETI data were included in the meta‐analysis instead of the ANELT data.

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 1 Functional communication.

Three trials used both the Token Test and the AAT auditory comprehension subtest to compare participants' auditory language skills ( Pulvermuller 2001 ; Sickert 2014 ; Wilssens 2015 ). Despite pooling the data from across these trials on each of these measures, there was no evidence of a difference between the groups ( Analysis 18.2 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 2 Receptive language: auditory comprehension.

Wilssens 2015 also compared the groups receiving CIAT versus a semantic SLT approach on the Semantic Association Test, the PALPA Semantic Association, the Auditory Lexical Decision test, and Auditory Synonym Judgement. There was no indication of a difference between the groups ( Analysis 18.3 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 3 Receptive language: other.

Investigators compared participants' naming abilities using the AAT naming subtest in three trials ( Pulvermuller 2001 ; Sickert 2014 ; Wilssens 2015 ), while one trial used the Boston Naming Test ( Wilssens 2015 ). On pooling the AAT naming subtest data, there was no evidence of a difference between the groups nor was there any indication of a difference on the BNT ( Analysis 18.4 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 4 Expressive language: naming.

There was no evidence of a difference between the groups' performance on measuring repetition using the AAT subtest in Pulvermuller 2001 , Sickert 2014 , and Wilssens 2015 nor when using the PALPA non‐words repetition subtest in Wilssens 2015 ( Analysis 18.5 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 5 Expressive language: repetition.

Expressive language: writing

Both Sickert 2014 and Wilssens 2015 measured participants' writing skills on the AAT writing subtests, but on pooling the data there was no evidence of a difference between the groups ( Analysis 18.6 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 6 Expressive language: written.

4. Quality of Life

VERSE II measured participants' quality of life using the SAQoL and found no evidence of a difference between those that received CIAT SLT and those that received a conventional SLT approach ( Analysis 18.7 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 7 Quality of life.

Only two trials measured the severity of participants' aphasia: Pulvermuller 2001 used the AAT overall score, and VERSE II used the WABAQ. On pooling the data, there was no evidence of a difference between the groups ( Analysis 18.8 ).

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Comparison 18 Constraint‐induced aphasia therapy versus other SLT, Outcome 8 Severity of impairment.

VERSE II measured participants' functional communication using a Discourse Analysis score, quality of life using the SAQoL, and the severity of aphasia using the WABAQ at 12 and 26 weeks follow‐up. There was no evidence of a difference between the groups that had received CIAT versus conventional SLT at these time points ( Analysis 19.1 ; Analysis 19.2 ; Analysis 19.3 ).

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Comparison 19 Constraint‐induced aphasia therapy versus other SLT (follow‐up), Outcome 1 Functional communication.

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Comparison 19 Constraint‐induced aphasia therapy versus other SLT (follow‐up), Outcome 2 Quality of life.

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Comparison 19 Constraint‐induced aphasia therapy versus other SLT (follow‐up), Outcome 3 Severity of impairment.

Experimental SLT versus other SLT

Additional studies evaluated a range of other experimental approaches to SLT versus an alternative SLT approach.

SLT with a gestural adjunct during language production.
Melodic intonation therapy (MIT)
Functional SLT
Operant training
Verb comprehension
Discourse therapy
Task‐specific naming and sentence production
Language oriented therapy
Systematic Therapy for Auditory Comprehension Disorders in Aphasic Patients (STACDAP)
Filmed programmed instruction

In most cases, investigators broadly described the comparison treatment as 'conventional' SLT. In MIT 2014i the comparison was to therapy that focused on language comprehension and written language, while in Crerar 1996 the comparison was to preposition therapy. Additionally, many of these experimental interventions were evaluated in randomised controlled trials that were feasibility studies in nature and have so far occurred in isolation. Thus, pooled analysis was not possible. For completeness within this review, however, we have presented these interventions below.

SLT with gestural adjunct versus 'conventional' SLT (no gesture)

Two trials compared conventional therapy (with no gestural movement) versus an SLT intervention with a gestural adjunct: Crosson 2014 by encouraging the use of a gesture during naming activities, and Drummond 1981 by supporting cueing. The format of the summary data reported within Drummond 1981 prevented inclusion in the meta‐analyses. We present data from Crosson 2014 comparing functional communication, expressive language and severity of aphasia measures post‐therapy and at three‐month follow‐up in Analysis 20.1 to Analysis 20.6 . There was no evidence of a significant difference between the groups.

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 1 Functional communication.

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 6 Severity of impairment: Aphasia Battery Score (follow‐up).

MIT versus SLT (excluding targeted spoken verbal production)

One trial compared a melodic intonation therapy approach (MIT) to SLT, focusing on written language production, language comprehension, and non‐verbal communication strategies (i.e. non‐language production target) ( MIT 2014i ). The data for this trial relating to measures of functional communication, expressive language (naming and repetition), and number of dropouts can be seen in Analysis 21.1 to Analysis 21.4 . Repetition of trained MIT items showed some evidence of effect, but otherwise there was no evidence of a difference between the groups. Data from MIT 2014ii are as yet unavailable.

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Comparison 21 Melodic intonation therapy versus other SLT, Outcome 1 Functional communication.

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Comparison 21 Melodic intonation therapy versus other SLT, Outcome 4 Number of dropouts for any reason.

Functional versus conventional SLT

The randomised comparison of a functional SLT approach with a conventional SLT intervention is presented as measured by ratings on the CETI ( Hinckley 2001 ). There was no evidence of a difference between the groups ( Analysis 22.1 ). Other data were available but only as change from baseline summary data and thus we did not include them here.

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Comparison 22 Functional SLT versus conventional SLT, Outcome 1 Functional communication.

Operant training SLT versus conventional SLT

The randomised comparisons taken from the cross‐over trials compared an operant training SLT intervention with conventional SLT plus an attention control ( Lincoln 1984b ; Lincoln 1982i ; Lincoln 1982ii ). We present these results separately within the data and analysis tables for information purposes ( Analysis 23.1 to Analysis 23.5 ). Lincoln 1982i and Lincoln 1982ii randomised participants across four groups that compared SLT plus an operant training adjunct versus SLT plus a social support and stimulation adjunct. In both of these trials, we extracted the means and SD from unpublished individual patient data, which are inclusive of the treatment cross‐over period. Given the complementary nature of the cross‐over intervention (SLT plus operant training or SLT plus social support) and the clinically relevant nature of the cross‐over treatments, we felt it was appropriate to include these data within the review. We present data relating to measures of receptive and expressive language and severity of aphasia in Analysis 23.1 to Analysis 23.5 .

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Comparison 23 Operant training SLT versus conventional SLT, Outcome 1 Receptive language: auditory comprehension.

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Comparison 23 Operant training SLT versus conventional SLT, Outcome 5 Severity of impairment.

Verb comprehension SLT versus preposition comprehension SLT

Crerar 1996 compared a computer‐mediated approach to verb comprehension therapy with a computer‐mediated preposition comprehension therapy. The trial had a cross‐over design, and we only included data collected prior to the point of cross‐over in the review. The participant group included people with acquired language impairment as a result of other neurological causes, and some participants in the main trial were not truly randomly allocated to an intervention, undergoing a quasi‐random allocation as a result of their language impairment profile, transport situation, or geographical location. We extracted and included in the review only the data from participants with aphasia as a result of stroke that underwent an adequate randomisation procedure. We present the data from the measures of receptive language, expressive language and severity of aphasia in Analysis 24.1 to Analysis 24.4 .

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Comparison 24 Verb comprehension SLT versus preposition comprehension SLT, Outcome 1 Receptive language: auditory comprehension.

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Comparison 24 Verb comprehension SLT versus preposition comprehension SLT, Outcome 4 Severity of impairment: Aphasia Battery Score.

Discourse therapy versus conventional SLT

One trial compared participants that received therapy aiming to support the development and production of discourse language with those that received conventional deficit‐focused SLT on measures of word, sentence and discourse performance across four discourse genre, measures of naming, sentence production, and comprehension ( NARNIA 2013 ). There was no evidence of a difference between the groups ( Analysis 25.1 to Analysis 25.3 ).

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Comparison 25 Discourse therapy versus conventional therapy, Outcome 1 Functional communication.

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Comparison 25 Discourse therapy versus conventional therapy, Outcome 3 Expressive language: naming.

Task‐specific naming and sentence production SLT versus conventional SLT

Van Steenbrugge 1981 compared participants that received a 'task‐specific' approach to SLT focused on naming and sentence production versus a conventional 'general stimulation' approach to SLT using measures of the Functional Expression (FE) Scale, measures of naming, and sentence construction. There was no evidence of a difference between the groups ( Analysis 26.1 to Analysis 26.6 ).

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 1 Functional communication.

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 6 Expressive language: treated items.

Language oriented therapy (LOT) versus conventional SLT

Based on psycholinguistic principles, Shewan 1984i compared LOT versus a conventional stimulation‐facilitation approach, using the WAB and the ACTS to measure outcomes but suitable summary data were unavailable and so these could not be included in the meta‐analyses. There was no evidence of a difference between the groups in relation to numbers of participants dropping out or adherence rates ( Analysis 27.1 ; Analysis 27.2 ).

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Comparison 27 Language oriented therapy (LOT) versus conventional SLT, Outcome 1 Number of dropouts for any reason.

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Comparison 27 Language oriented therapy (LOT) versus conventional SLT, Outcome 2 Adherence to allocated intervention.

Task‐specific SLT versus conventional SLT

Prins 1989 compared an SLT intervention focusing specifically on auditory comprehension problems (STACDAP) versus conventional stimulation therapy using functional communication indicators and receptive and expressive language outcome measures. There was no evidence of a difference between the groups ( Analysis 28.1 to Analysis 28.7 ).

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 1 Functional communication.

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 7 Expressive language: spoken sentence.

Filmed programme instruction plus SLT versus conventional SLT

Di Carlo 1980 compared the use of a filmed adjunct to SLT with conventional SLT approaches on measures of receptive language. There was no evidence of a difference between the groups ( Analysis 29.1 ) .

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Comparison 29 FIlmed programme instruction versus conventional SLT, Outcome 1 Expressive language: naming.

We updated this complex review of the effectiveness of SLT interventions for people with aphasia following stroke to reflect new evidence and developments in clinical practice. We assessed whether SLT is more effective than no SLT, whether SLT is more effective than social support and stimulation, and whether one SLT intervention is more effective than another. We identified, synthesised and presented data from 57 trials (and 3002 participants) in this review.

Summary of main results

Our review includes information on a total of 3002 participants randomised across 74 comparisons. We synthesise the data into three broad comparisons, and we consider these findings below as they relate to SLT versus no SLT, SLT versus social support, and one type of SLT versus a different SLT approach.

SLT versus no SLT

Based on 27 trials involving 1620 participants, we found significant differences between the scores of participants who received SLT and those that did not. Specifically, these differences were evidenced in measures of functional communication, receptive language (including reading), and expressive language (including writing), all of which favoured the provision of SLT ( Table 1 ). However, significant differences were not evident across all measures. Sample sizes remain small, and there is some indication of one or two trials' highly significant findings impacting upon the meta‐analyses. We have profiled the available evidence relating to therapy follow‐up data from these trials which is (as yet) limited in the number of trials and contributing participants ( Table 2 ).

We observed notable statistical heterogeneity among some of the SLT versus no SLT comparisons (e.g. expressive language: general, I 2 = 76% and the severity of impairment comparison, I 2 = 93%). In addition, we also noted measures based on either the Aphasia Battery of Chinese or the Chinese Aphasia Measurement tools fell outside of the 95% CIs of the associated funnel plots. While we might expect that a proportion (5%) of the results would be observed in this manner by chance, the frequency of the observation is above what we might expect to occur by chance alone. There are a number of possible explanations for these observations. The Cochrane Handbook for Systematic Reviews of Interventions suggests consideration of several possible sources of heterogeneity and asymmetry in funnel plots. Selection bias, poor methodological quality, true heterogeneity, artefact, or chance may have contributed ( Higgins 2011 ). Zhang 2007i , Zhang 2007ii and Zhao 2000 took place in China, where doctors and nurses deliver SLT interventions rather than professional therapists, as may be the case for the other trials in this meta‐analysis. Other aspects of stroke care may also have differed. We also have limited information on the study populations included within these trials, particularly from the Zhao 2000 trial, which does not report time post onset, patient demographics or aphasia severity. Information on the methodological design is also very limited, particularly in relation to the randomisation, concealment of allocation, and blinding of outcome assessors.

Abstracts of these Chinese trials were published in English, thus the contribution of professional translators unfamiliar with some of the technical specifications or methodological terms used in health services research may have had an impact. Within these articles, authors report that the participants within the trials were randomised to the different interventions. Thus, they were eligible for inclusion within this review. Our attempts to access trial details similarly required translation of the trial reports, which may also have introduced some discrepancies between the original meaning of the trialists and our translations. The exact nature of the randomisation processes is unclear, and if we look at the sample sizes of the groups (within Zhao 2000 for example), there is considerable imbalance between the numbers that received SLT (98 participants) and those that did not (40 participants) raising further questions regarding the randomisation processes employed within some studies. Information about some of the tools (and subtests of these tools) used within these trials (such as the Aphasia Battery of Chinese or the Chinese Aphasia Measurement) were unavailable to us. Our pooling of data relating to 'verbal presentation' may not exactly capture the same aspects of verbal expression as other tools within our meta‐analysis. Similarly, issues relating to the tools' validity and reliability were unavailable. Despite our best efforts, we failed to communicate with the Zhang 2007i , Zhang 2007ii or Zhao 2000 trialists to confirm or obtain clarification on any of these issues. In the meantime, the reader should be mindful of the inconsistencies observed within our meta‐analyses when interpreting the findings from this section of the review. We look forward to the availability of the currently ongoing trials in the future, which will further inform this comparison.

SLT versus social support

A total of 447 people were randomised across nine trials to receive either SLT or a social support and stimulation intervention. While we observed some significant differences in the performance of the groups on various measures of language performance (favouring those that received social support), most findings were derived from one small trial of 18 participants ( Lincoln 1982iii ). The more recent, large, rigorously conducted ACTNoW 2011 trial found no evidence of a significant difference between the functional language skills of the two groups. Additional data are required to confirm whether social support and stimulation provides benefits to some aspects of participants' language skills and on measures of severity of aphasia impairment. In contrast, other significant differences observed (informed by five trials in this comparison) showed that significantly more participants allocated to social support and stimulation interventions dropped out or did not adhere to the intervention when compared with the participants allocated to SLT. While social support and stimulation may be beneficial to some aspects of participants' language performance, we need additional evidence to support this. Where social support and stimulation interventions are being delivered, practitioners should provide clear explanation of the nature and purpose of the support to individuals to reduce any dissatisfaction that might be experienced and which may have resulted in the significantly higher dropout rates observed.

SLT A versus SLT B

Thirty‐eight trials, involving 1242 participants, compared two different types of SLT. This section of the review has grown considerably since our 2012 review, and thus we were able to compare different therapy regimens (differing in intensity, dosage and duration), different therapy delivery models (group, one‐to‐one, volunteer, computer facilitated) and different theoretical approaches (e.g. constraint‐induced therapy, semantic therapy). In general, comparisons continue to be based on a small number of trials involving few participants (typically less than 20). Additional data are still required to further inform these comparisons. The effectiveness of popular SLT approaches such as functional SLT or constraint‐induced aphasia therapy were informed by a small number of trials and did not demonstrate evidence of the effectiveness of these approaches over conventional SLT approaches. Some of the data from these trials were unavailable to this review, so we could not include them in the meta‐analyses. While we hope that these data may become available in the future, we are also looking forward to the availability of data from ongoing trials, which will further inform these comparisons.

There was little evidence of any difference between group SLT and one‐to‐one SLT, computer‐facilitated, or volunteer‐facilitated SLT versus professional SLT, although these comparisons were based on limited numbers of trials involving small numbers of participants. The available evidence, however, indicates there is no evidence of a difference in the provision of SLT interventions facilitated by volunteers or computers (under the direction of professional therapists and with appropriate access to relevant therapy materials and therapeutic intervention plans) compared with direct therapy provision by a professional therapist.

We identified eight trials that compared high‐intensity to low‐intensity SLT. There was some indication of benefits to participants' functional language skills based on the synthesis of data from two trials. Based on pooled data from five different trials, we also observed improvements in severity of aphasia following high‐intensity SLT. However, the number of participants dropping out from the high‐intensity SLT groups was significantly higher than in the low‐intensity SLT groups, confounding the results and suggesting that high‐intensity approaches to therapy (4 to 15 hours per week) may not be suited to all patients. Following Cochrane editorial review, we considered the timing of participant recruitment to the contributing trials as a possible factor to the tolerance of high‐intensity interventions. The trials contributing to this analyses recruited with two weeks (two RCTs), one to three months (four RCTs), and between two to eight years (two RCTs) after onset of aphasia. Effects were no longer observed in a post hoc comparison of trials recruiting participants several years after stroke (nor did those trials report any dropouts). The beneficial effect remained for trials that recruited within three months of aphasia onset, although the significantly higher dropouts from the high‐intensity groups came only from those trials. Similarly, we observed some indication of a benefit of a high dose of therapy (between 60 and 208 hours of therapy) compared with a lower dose of SLT (ranging from 5 to 78 hours), but significant differences were based on findings from a single trial with small numbers of participants. However, where trial data overlapped, as in the number of trial dropouts reported by three trials, the participants who received the lower dose of therapy were less likely to drop out than those that received the higher dose.

It is possible that the timing of an intervention after stroke may be an important factor in both the effectiveness of and tolerance to specific intervention approaches. There are possible interactions between specific individual, aphasia and stroke profiles and the characteristics of complex SLT interventions that vary by intervention regimen, delivery model, and theoretical approach. Exploration of these issues is not suited to Cochrane review methodologies. Instead a large, international, multidisciplinary collaboration of aphasia researchers is aiming to examine such aspects through the RELEASE project.

Overall completeness and applicability of evidence

We identified a substantial number of trials of relevance to our review; most were eligible for inclusion. Across the included trials there was a lack of comprehensive data collection, a wide range of outcome tools employed, and disappointingly inadequate reporting of outcome measures. Many of the trialists generously shared unpublished data and supplementary information to enable accurate representation of their trial in this review. We are very grateful for their time and efforts to provide this information.

Within the review, just over half of the trials described measuring receptive (N = 45) and expressive language skills (N = 56), but not all reported suitable data in a published format that permitted inclusion within this review. We were able to include most trials that described measures of receptive language (67%; N = 30/45) and most expressive language measures (66%; N = 37/56). Forty‐seven trials evaluated the severity of participants' aphasia impairment, and we included suitable data from 29 trials. Similarly, while five trials reported measuring economic outcomes, only data from two were available. Many trials measured participants' functional and psychosocial outcomes, measures that are probably most closely aligned to the patients' sense of recovery and return to 'normal'. From the total of 74 randomised comparisons, more than half (N = 44) described measuring changes in functional communication and of these, most (N = 33/44) reported data that could be included within the meta‐analyses. Few trials measured psychosocial outcomes (N = 8) with five reporting (or providing) data suitable for inclusion within the review.

The degree to which the models of conventional SLT employed within the trials are reflective of therapists' current practice should be carefully considered across individual treatments in terms of the frequency, duration, and the extent of therapeutic intervention. To this end, we employed the TIDieR Checklist to support full data extraction of the SLT interventions within the trials ( Hoffmann 2014 ). In this way, the reader has access to a more comprehensive overview of the interventions being compared in the Characteristics of included studies table. Participants came from across a wide age range and were experiencing a range of aphasia impairments. However, the length of time since participants' stroke raises questions of how clinically relevant some recruitment parameters were to an SLT clinical population.

Less than a fifth (N = 13; 18%) of the included trials recruited participants within the first month following their stroke (a participant group of high clinical relevance) and only four of these recruited participants within the first week after their stroke ( Laska 2011 ; Mattioli 2014 ; VERSE I ; VERSE II ). Most recruited participants more than one month, and in some cases many years following their stroke (N = 49), or they did not report the time post onset (N = 12; FUATAC ; SEMaFORE ; Smith 1981i ; Smith 1981ii ; Smith 1981iii ; Szaflarski 2014 ; Wu 2004 ; Xie 2002 ; Yao 2005i ; Yao 2005ii ; Yao 2005iii ; Zhao 2000 ). Recruitment procedures involving participants up to 29 years after the onset of their aphasia are of limited application to either a clinical or treatment evaluation setting and raise the question of whether such inclusion criteria are apt to demonstrate effectiveness of an SLT intervention.

Our 2016 update adds a significant amount of data and so, together with continually improving systematic review and reporting methodologies, we are in a better position to draw conclusions regarding the effectiveness of SLT for aphasia following stroke. This review included a total of 74 randomised comparisons involving data from 3002 individual patients.

Methods of random sequence generation and concealment of allocation were considered adequate in 35 and 25 trials, respectively ( Figure 2 ; Figure 3 ). The randomisation methodology for the remaining trials had been inadequately described, so it was not possible to judge the quality. Similarly, only seven trials reported information on allocation concealment. The lack of description and detail does not necessarily mean inadequate procedures were in place but rather a lack of reporting of this detail ( Soares 2004 ). The prevalence of good methodology in relation to blinding of outcome assessors supports this interpretation, as more than half of the trials within the review (N = 43) described adequate blinding procedures. We only considered 11 to have inadequately blinded assessors, while 20 provided too little detail to make a judgement.

Half of the trials in this review (N = 36, 49%) were published before the CONSORT statement (Consolidated Standards of Reporting Trials) ( Altman 2001 ; Moher 2001 ). Disappointingly, of the 38 trials published from 2005 (and after the implementation of the CONSORT statement) only 25 (66%) reported adequate methods of generating the randomisation sequence, and only 19 (50%) reported adequate methods of concealing allocation. Of the 20 that failed to adhere to the CONSORT statement ( B.A.Bar 2011i ; B.A.Bar 2011ii ; Conklyn 2012 ; Crosson 2014 ; FUATAC ; Laska 2011 ; Liu 2006a ; Mattioli 2014 ; Meinzer 2007 ; ORLA 2006 ; ORLA 2010 ; Rochon 2005 ; Smania 2006 ; Szaflarski 2014 ; Wu 2013 ; Yao 2005i ; Yao 2005ii ; Yao 2005iii ; Zhang 2007i ; Zhang 2007ii ), seven were published in Chinese medicine or nursing journals, and three were based on an abstract or short report of a full trial ( FUATAC ; ORLA 2006 ; Szaflarski 2014 ). It is essential that future trial reports adhere to these internationally accepted standards of trial reporting.

Twelve trials reported an a priori power size calculation, which is reflected in the small numbers of randomised participants across the trials included in the review ( ACTNoW 2011 ; B.A.Bar 2011i ; Doesborgh 2004 ; Laska 2011 ; MIT 2014i ; MIT 2014ii ; NARNIA 2013 ; RATS ; RATS‐2 ; SP‐I‐RiT ; Varley 2016i ; Varley 2016ii ). Nine randomised 10 or fewer participants; 43 randomised up to 50 participants; 16 randomised between 51 and 100 participants; two randomised over 100 participants and only four involved 150 individuals or more. The randomisation of such relatively small numbers of participants reduces the power of the statistical analyses, raises questions of the reliability of findings and (given the complexity of various aphasia impairments) causes difficulties in ensuring the comparability of the groups at baseline. Fifteen of the included trials had groups that significantly differed at baseline, and group comparability was unclear in another 10 randomised comparisons.

Despite these reporting and methodological limitations, we have synthesised a large number of trials that address the effectiveness of SLT for aphasia following stroke across a number of outcome measures. Across these measures, there is evidence of the effectiveness of SLT for people with aphasia when compared with no therapy provision. While the consistency in the direction of results observed in the previous version of this review remains following the inclusion of additional trial data, many of the significant differences between pooled data from patients that received SLT and those that did not include data from a single three‐armed trial ( Zhang 2007i ; Zhang 2007ii ). Caution is required in interpreting this trial evidence, as the randomisation procedure, concealment of allocation, blinding, and even details of the SLT intervention evaluated (contents, duration, frequency, intensity) are unclear.

With at least 18 additional trials of relevance to this review currently ongoing or about to report, the picture based on the current evidence for SLT for aphasia following stroke will develop further over time. We can be confident that with the availability of well‐conducted and reported trials, the evidence will continue to strengthen, providing more indications of the effectiveness of specific approaches to SLT.

Thirty‐one of the 74 trials in this review included all randomised participants in their final analyses. The remaining 43 trials lost participants during the treatment or follow‐up phases, but only eleven employed an ITT analysis. In some cases large proportions of participants withdrew from some interventions, and at times this appeared to be linked to the intervention itself, with significantly more participants withdrawing from both intensive SLT and social support interventions than from comparator SLT interventions. Similarly, there was evidence of significantly fewer people adhering to their allocated intervention when that intervention was a social support intervention and a trend towards this when the intervention was a high‐intensity SLT.

Potential biases in the review process

Within this review, we expanded the 2012 search strategy and conducted a comprehensive search for high quality trials that evaluated the effectiveness of SLT for aphasia following stroke. While we are confident we have identified most published trials of relevance to the review, it is still possible that despite our efforts, we may be unaware of additional unpublished work. Our search strategy and study selection criteria were agreed in advance and applied to all identified trials. Our data extraction processes were completed independently and then compared. Whenever possible, we extracted all relevant data and sought missing data directly from the trialists for inclusion within the review. We considered it appropriate to include cross‐over data within our review given the nature of the comparisons, the points at which the data were extracted and, in some cases, the availability of individual patient data.

This review has been informed by the availability of individual patient data (N = 323). In three trials the individual data were presented within the associated publications, while for the remaining 10 trials we are very grateful to the trialists for access to their unpublished data, facilitating inclusion of their trial data within the review. In addition, other trialists generously contributed the relevant summary values thus permitting the full inclusion of important trials from this field within the meta‐analyses (e.g. Wertz 1986i ; Wertz 1986ii ; Wertz 1986iii ). However, there still remain a number of other relevant trials that could not be fully included.

Agreements and disagreements with other studies or reviews

One of the first reviews in this area was Robey 1994 , which included 21 published studies (restricted to English language but not to RCTs). The reviewers identified at least 19 more studies that they were unable to include because of the manner in which the data had been reported. They concluded that the provision of SLT in the acute stages of aphasia following stroke was twice as effective as natural recovery patterns. Delayed therapy had a smaller, though still evident, impact. The authors called for better reporting of data and the use of large sample sizes. This team later updated their review, employing the same methodologies and including 55 studies that focused specifically on the amount and type of SLT intervention and its impact on the severity and type of aphasia ( Robey 1998a ). Again, they concluded that SLT was effective, particularly SLT in the acute stages following stroke and if two or more hours of therapy were provided each week. However, they again did not have access to all the relevant data, and they excluded some key trials, such as Wertz 1986 .

Bhogal 2003 reviewed 10 English language publications of controlled trials from a MEDLINE search (1975 to 2002) and associated references. They found that intensive SLT delivered significant treatment effects (when at least nine hours per week were delivered) and that studies that failed to demonstrate a treatment effect had only provided about two hours of SLT per week. The total duration of SLT provision was also negatively correlated with language outcomes. Cherney 2008 also reviewed 10 English language publications (1990 to 2006; 15 electronic databases; not all RCTs) and found modest evidence for intensive SLT and benefits of constraint‐induced aphasia therapy.

In contrast, Moss 2006 reviewed 23 single patient reports involving the provision by a therapist on a one‐to‐one basis of SLT that targeted spoken output or auditory comprehension in 57 participants identified following a systematic search (1985 to 2003) of published or indexed work. They concluded that time since stroke (and aphasia onset) is not linked to the response to SLT though they indicate (based on their data) that response to SLT may decline eight years after stroke. However, the highly selective nature of participants in published single cases studies means that reviews based on such a population group are of questionable applicability to a general clinical population. Individuals (and their caregivers) within such reports are likely to be highly motivated, educated, dedicated, and reliable therapy participants ( Moss 2006 ).

Implications for practice

Our review presents evidence of the benefits of SLT for people with aphasia following stroke as measured by their functional communication, reading, comprehension, expressive language, and writing. While there is an overall consistency in the findings across all trials included in these analyses, some of our significant findings were dependent on data from a single trial with limited information on the nature of the SLT intervention and the quality of the trial. Thus, we must exercise some caution in interpreting these results. It is also of note that the SLT provided in the included trials could be considered to be at a high level of intensity over variable periods of time.

Based on a smaller number of trials, we also observed some indication of the benefits of high‐intensity approaches to SLT in relation to functional communication and severity of impairment. The intensity of the interventions varied, as did the duration of therapy input, but such high‐intensity approaches to SLT may not have suited all participants. Significantly more participants in the intensive groups dropped out from these trials than from the non‐intensive groups.

Similarly, one small trial indicated that social support and stimulation may be beneficial to some aspects of patients' language skills, but the findings were confounded by a significantly higher participant dropout from social support interventions than from SLT interventions.

There was insufficient evidence within this review to establish the effectiveness of one SLT theoretical approach over another, with little indication of a difference between group SLT versus one‐to‐one SLT, and computer‐mediated SLT versus therapist‐delivered SLT. Similarly, there was little indication of a difference in the effectiveness of SLT facilitated by a trained volunteer versus SLT delivered by a therapist. This is unsurprising, as the volunteers in these trials received specialist training, had access to therapy materials and in many cases were delivering therapy interventions designed and overseen by a professional therapist. This model of SLT treatment delivery is often used in the UK.

Implications for research

In the course of updating this review, we identified many ongoing trials and trials that are about to report findings. In this context of a rapidly developing evidence base, there will be a need to update the findings of this review once the results of these ongoing trials become available. As aphasia researchers, we need to continue to improve the quality of SLT trials conducted. It is in pursuit of this goal that the Collaboration of Aphasia Trialists has been established. Funded by the European COST Association, this international collaboration of multidisciplinary aphasia researchers seek to enhance the development, conduct, and reporting of aphasia research. Aphasia researchers, funders, reviewers, and editors should be encouraged to publish all findings from completed trials. Investigators should adhere to the recommendations of the CONSORT statement, thus ensuring that the quality of the trial is fully demonstrated in the published report ( Altman 2001 ; Moher 2001 ). In addition, the recent TIDieR guidelines seek to support better reporting of complex interventions such as SLT for aphasia and to ensure the transparency and transferability of research approaches into clinical practice ( Hoffmann 2014 ). These guidelines have also enhanced the description and profiling of included trial SLT interventions within our Characteristics of included studies table. Trialists should also provide full descriptions of the relevant statistical summary data (means and SDs of final value scores) thus allowing inclusion of their data within any subsequent relevant meta‐analyses. A priori sample size calculations should be employed, ensuring SLT trials are adequately powered to demonstrate differences. The challenge for SLT researchers and clinicians will be to design, develop, conduct, and support larger trials. It is essential for the success of these trials that the work is undertaken in a collaborative manner between patients, clinicians, and researchers. Standardised outcome measures should be employed to evaluate the impact of SLT on participants' functional communication, expressive and receptive language skills, and the severity of their aphasia. We welcome the work currently ongoing in the ROMA study to achieve international consensus on a minimum core data set for aphasia research.

Supported by UK NIHR funding, the RELEASE project is conducting a more detailed examination of the effectiveness of SLT and the interaction between specific individuals, aphasia and stroke profiles, therapy regimens, theoretical approaches, and delivery models. The internationally collaborative group of aphasia researchers is gathering individual patient data from across more than 50 pre‐existing aphasia research studies for the purposes of secondary data analyses, which will specifically examine many of the issues raised in this review. Additional expressions of interest in contribution of aphasia research data sets are welcome.

Our overall aim for future research should be to establish what is the optimum approach, frequency, duration of allocation, and format of SLT provision for specific patient groups.

Protocol first published: Issue 4, 1997 Review first published: Issue 4, 1999

Acknowledgements

We acknowledge Jenny Greener and Renata Whurr, authors of the original review, and the significant contribution the original review made to the field.

We thank Hazel Fraser for her comments and suggestions for this review and for providing us with relevant trials from the Cochrane Stroke Group's Trials Register, and Brenda Thomas for her help with developing the search strategy.

We thank the Cochrane Stroke Group editors and all those who commented on the draft version of this review update, in particular Peter Langhorne, Tammy Hoffmann, Leora Cherney, Valentina Assi, and Tam Watson.

We are grateful to the Chinese Cochrane Centre, Christine Versluis, Audrey Morrison, Theresa Ikegwuonu, Floortje Klijn, Bart Lamers, Pei‐Ling Choo, and Ying Man Law for translations.

We thank all the trialists who patiently responded to our queries, provided translations, and generously contributed unpublished data and additional information to this review.

Appendix 1. Assessments

Appendix 2. cochrane library databases.

Cochrane Library databases (CDSR, DARE, CENTRAL, HTA) from inception to 22 September 2015

#1 [mh aphasia]

#2 [mh ^"language disorders"] or [mh ^"speech disorders"] or [mh ^anomia]

#3 (aphasi* or dysphasi* or anomia or anomic):ti,ab

#4 ((speech or language* or linguistic or communicat*) near/5 (disorder* or impair* or problem* or dysfunction or difficult*)):ti,ab

#5 #1 or #2 or #3 or #4

#6 [mh aphasia/RH,TH] or [mh ^"language disorders"/RH,TH] or [mh ^"speech disorders"/RH,TH] or [mh ^anomia/RH,TH]

#7 [mh ^"speech‐language pathology"] or [mh "rehabilitation of speech and language disorders"]

#8 ((speech or language* or linguistic or aphasi* or dysphasi* or anomia or anomic) near/5 (therap* or train* or rehabilitat* or treat* or remediat* or intervention* or pathol*)):ti,ab

#9 (SLT or SLP):ti,ab

#10 (melodic next intonation next therap* or MIT):ti,ab

#11 #6 or #7 or #8 or #9 or #10

#12 #5 and #11

#13 (pediatric or paediatric or infant or infants or child or children* or childhood or neonat* or juvenile* or toddler*):ti

#14 ([mh ^child] or [mh ^"child, preschool"] or [mh ^"adult children"] or [mh ^adolescent] or [mh infant]) not [mh adult]

#15 #13 or #14

#16 #12 not #15

Appendix 3. MEDLINE search strategy

MEDLINE (Ovid) from 1946 to 22 September 2015

1. exp aphasia/

2. language disorders/ or speech disorders/ or anomia/

3. (aphasi$ or dysphasi$ or anomia or anomic).tw.

4. ((speech or language$ or linguistic or communicat$) adj5 (disorder$ or impair$ or problem$ or dysfunction or difficult$)).tw.

5. 1 or 2 or 3 or 4

6. exp aphasia/rh, th or language disorders/rh, th or speech disorders/rh, th or anomia/rh, th

7. speech‐language pathology/ or exp "rehabilitation of speech and language disorders"/

8. ((speech or language$ or linguistic or aphasi$ or dysphasi$ or anomia or anomic) adj5 (therap$ or train$ or rehabilitat$ or treat$ or remediat$ or intervention$ or pathol$)).tw.

9. (SLT or SLP).tw.

10. (melodic intonation therap$ or MIT).tw.

11. 6 or 7 or 8 or 9 or 10

12. Randomized Controlled Trials as Topic/

13. random allocation/

14. Controlled Clinical Trials as Topic/

15. control groups/

16. clinical trials as topic/ or clinical trials, phase i as topic/ or clinical trials, phase ii as topic/ or clinical trials, phase iii as topic/ or clinical trials, phase iv as topic/

17. double‐blind method/

18. single‐blind method/

19. Placebos/

20. placebo effect/

21. cross‐over studies/

22. randomized controlled trial.pt.

23. controlled clinical trial.pt.

24. (clinical trial or clinical trial phase i or clinical trial phase ii or clinical trial phase iii or clinical trial phase iv).pt.

25. (random$ or RCT or RCTs).tw.

26. (controlled adj5 (trial$ or stud$)).tw.

27. (clinical$ adj5 trial$).tw.

28. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.

29. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw.

30. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.

31. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.

32. (cross‐over or cross over or crossover).tw.

33. (placebo$ or sham).tw.

34. trial.ti.

35. (assign$ or allocat$).tw.

36. controls.tw.

37. or/12‐36

38. 5 and 11 and 37

39. exp animals/ not humans.sh.

40. 38 not 39

41. (pediatric or paediatric or infant or infants or child or children$ or childhood or neonat$ or juvenile$ or toddler$).ti.

42. (child/ or child, preschool/ or adult children/ or adolescent/ or exp infant/) not exp adult/

43. 41 or 42

44. 40 not 43

Appendix 4. EMBASE search strategy

EMBASE (Ovid) from 1980 to 22 September 2015

1. exp aphasia/ or dysphasia/

2. language disability/ or speech disorder/

6. exp aphasia/rh, th, dm or dysphasia/rh, th, dm or language disability/rh, th, dm or speech disorder/rh, th, dm

7. exp speech rehabilitation/

12. Randomized Controlled Trial/ or "randomized controlled trial (topic)"/

13. Randomization/

14. Controlled clinical trial/ or "controlled clinical trial (topic)"/

15. control group/ or controlled study/

16. clinical trial/ or "clinical trial (topic)"/ or phase 1 clinical trial/ or phase 2 clinical trial/ or phase 3 clinical trial/ or phase 4 clinical trial/

17. Crossover Procedure/

18. Double Blind Procedure/

19. Single Blind Procedure/ or triple blind procedure/

20. placebo/ or placebo effect/

21. (random$ or RCT or RCTs).tw.

22. (controlled adj5 (trial$ or stud$)).tw.

23. (clinical$ adj5 trial$).tw.

24. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.

25. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw.

26. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.

27. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.

28. (cross‐over or cross over or crossover).tw.

29. (placebo$ or sham).tw.

30. trial.ti.

31. (assign$ or allocat$).tw.

32. controls.tw.

33. or/12‐32

34. 5 and 11 and 33

35. (exp animals/ or exp invertebrate/ or animal experiment/ or animal model/ or animal tissue/ or animal cell/ or nonhuman/) not (human/ or normal human/ or human cell/)

36. 34 not 35

37. (paediatric or paediatric or infant or infants or child or children$ or childhood or neonate$ or juvenile$ or toddler$).it.

38. (child/ or juvenile/ or exp infant/ or preschool child/ or school child/ or toddler/) not (adult/ or aged/ or middle aged/ or young adult/)

39. 37 or 38

40. 36 not 39

Appendix 5. CINAHL search strategy

CINAHL (EBSCO) from 1982 to 22 September 2015

S1 .(MH "Aphasia+")

S2 .(MH "Speech Disorders") or (MH "Language Disorders") or (MH "Anomia")

S3 .TI ( aphasi* or dysphasi* or anomia or anomic ) OR AB ( aphasi* or dysphasi* or anomia or anomic )

S4 .TI ((speech or language* or linguistic or communicat*) N5 (disorder* or impair* or problem* or dysfunction or difficult*)) or AB ((speech or language* or linguistic or communicat*) N5 (disorder* or impair* or problem* or dysfunction or difficult*))

S5 .S1 OR S2 OR S3 OR S4

S6 .(MH "Aphasia+/RH/TH") or (MH "Speech Disorders/RH/TH ") or (MH "Language Disorders/RH/TH ") or (MH "Anomia/RH/TH ")

S7 ..(MH "Rehabilitation, Speech and Language") or (MH "Speech‐Language Pathologists") or (MH "Speech‐Language Pathology") or (MH "Speech Therapy+") or (MH "Language Therapy")

S8 .TI ((speech or language or linguistic or aphasi* or dysphasi* or anomia or anomic) N5 (therap* or train* or rehabilitat* or treat* or remediat* or intervention* or pathol*)) or AB ((speech or language or linguistic or aphasi* or dysphasi* or anomia or anomic) N5 (therap* or train* or rehabilitat* or treat* or remediat* or intervention* or pathol*))

S9 .TI (SLT or SLP) or AB (SLT or SLP)

S10 .TI (melodic intonation therap* or MIT) or AB (melodic intonation therap* or MIT)

S11 .S6 OR S7 OR S8 OR S9 OR S10

S12 .(MH "Randomized Controlled Trials") or (MH "Random Assignment") or (MH "Random Sample+")

S13 .(MH "Clinical Trials") or (MH "Intervention Trials") or (MH "Therapeutic Trials")

S14 .(MH "Double‐Blind Studies") or (MH "Single‐Blind Studies") or (MH "Triple‐Blind Studies")

S15 .(MH "Control (Research)") or (MH "Control Group") or (MH "Placebos") or (MH "Placebo Effect")

S16 .(MH "Crossover Design") OR (MH "Quasi‐Experimental Studies")

S17 .PT (clinical trial or randomized controlled trial)

S18 .TI (random* or RCT or RCTs) or AB (random* or RCT or RCTs)

S19 .TI (controlled N5 (trial* or stud*)) or AB (controlled N5 (trial* or stud*))

S20 .TI (clinical* N5 trial*) or AB (clinical* N5 trial*)

S21 .TI ((control or treatment or experiment* or intervention) N5 (group* or subject* or patient*)) or AB ((control or treatment or experiment* or intervention) N5 (group* or subject* or patient*))

S22 .TI ((control or experiment* or conservative) N5 (treatment or therapy or procedure or manage*)) or AB ((control or experiment* or conservative) N5 (treatment or therapy or procedure or manage*))

S23 .TI ((singl* or doubl* or tripl* or trebl*) N5 (blind* or mask*)) or AB ((singl* or doubl* or tripl* or trebl*) N5 (blind* or mask*))

S24 .TI (cross‐over or cross over or crossover) or AB (cross‐over or cross over or crossover)

S25 .TI (placebo* or sham) or AB (placebo* or sham)

S26 .TI trial

S27 .TI (assign* or allocat*) or AB (assign* or allocat*)

S28 .TI controls or AB controls

S29 .TI (quasi‐random* or quasi random* or pseudo‐random* or pseudo random*) or AB (quasi‐random* or quasi random* or pseudo‐random* or pseudo random*)

S30 .S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29

S31 .S5 AND S11 AND S30

S32 .TI (pediatric or paediatric or infant or infants or child or children* or childhood or neonat* or juvenile* or toddler*)

S33 .((MH "Adolescence+") or (MH "Child+") or (MH "Infant+")) not (MH "Adult")

S34 .S32 OR S33

S35 .S31 not S34

Appendix 6. AMED search strategy

AMED (Ovid) from 1985 to 22 September 2015

1. aphasia/

2. language disorders/ or speech disorders/

6. speech language pathology/ or speech therapy/ or language therapy/

7. ((speech or language$ or linguistic or aphasi$ or dysphasi$ or anomia or anomic) adj5 (therap$ or train$ or rehabilitat$ or treat$ or remediat$ or intervention$ or pathol$)).tw.

8. (SLT or SLP).tw.

9. (melodic intonation therap$ or MIT).tw.

10. 6 or 7 or 8 or 9

11. clinical trials/ or randomized controlled trials/ or random allocation/

12. research design/ or comparative study/

13. double blind method/ or single blind method/

14. placebos/

15. (random$ or RCT or RCTs).tw.

16. (controlled adj5 (trial$ or stud$)).tw.

17. (clinical$ adj5 trial$).tw.

18. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.

19. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw.

20. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.

21. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.

22. (cross‐over or cross over or crossover).tw.

23. (placebo$ or sham).tw.

24. trial.ti.

25. (assign$ or allocat$).tw.

26. controls.tw.

27. or/11‐26

28. 5 and 10 and 27

29. (pediatric or paediatric or infant or infants or child or children$ or childhood or neonat$ or juvenile$ or toddler$).ti.

30. (exp adolescent/ or exp child/ or exp infant/) not exp adult/

31. 29 or 30

32. 28 not 31

Appendix 7. Speech and language therapy approaches

Appendix 8. search strategies used in previous versions of this review.

For the original version of the review searches of MEDLINE (1966 to 1998) and CINAHL (1982 to 1998) were carried out using simple combinations of text words describing aphasia and SLT. We also searched major trials registers for ongoing trials including ClinicalTrials.gov (http://www.clinicaltrials.gov/), the Stroke Trials Registry (www.strokecenter.org/trials/) and Current Controlled Trials (www.controlled‐trials.com).

MEDLINE (Ovid) ‐ 2011 review

1. exp aphasia/ 2. language disorders/ or anomia/ 3. (aphasi$ or dysphasi$ or anomia or anomic).tw. 4. ((language or linguistic) adj5 (disorder$ or impair$ or problem$ or dysfunction)).tw. 5. 1 or 2 or 3 or 4 6. language therapy/ or speech therapy/ 7. Speech‐Language Pathology/ 8. ((speech or language or aphasia or dysphasia) adj5 (therap$ or train$ or rehabilitat$ or treat$ or remediat$ or pathol$)).tw. 9. remedial therap$.tw. 10. 6 or 7 or 8 or 9 11. 5 and 10 12. exp aphasia/rh, th or language disorders/rh, th or anomia/rh, th 13. 11 or 12 14. Randomized Controlled Trials/ 15. random allocation/ 16. Controlled Clinical Trials/ 17. control groups/ 18. clinical trials/ 19. double‐blind method/ 20. single‐blind method/ 21. Multicenter Studies/ 22. Therapies, Investigational/ 23. Research Design/ 24. Program Evaluation/ 25. evaluation studies/ 26. randomized controlled trial.pt. 27. controlled clinical trial.pt. 28. clinical trial.pt. 29. multicenter study.pt. 30. evaluation studies.pt. 31. random$.tw. 32. (controlled adj5 (trial$ or stud$)).tw. 33. (clinical$ adj5 trial$).tw. 34. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw. 35. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw. 36. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw. 37. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw. 38. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw. 39. (coin adj5 (flip or flipped or toss$)).tw. 40. latin square.tw. 41. versus.tw. 42. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw. 43. controls.tw. 44. or/14‐43 45. 13 and 44 46. child$.ti. 47. 45 not 46

EBSCO Search Strategy ‐ 2011 review

S44 S42 not S43 S43 TI child* S42 S18 and S41 S41 S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S32 or S33 or S36 or S37 or S40 S40 S38 and S39 S39 TI ( group* or subject* or patient* ) or AB ( group* or subject* or patient* ) S38 TI ( control or treatment or experiment* or intervention ) or AB ( control or treatment or experiment* or intervention ) S37 TI ( assign* or alternate or allocat* or counterbalance* or multiple baseline* or ABAB design* ) or AB ( assign* or alternate or allocat* or counterbalance* or multiple baseline* or ABAB design* ) S36 S34 and S35 S35 TI trial* or AB trial* S34 TI ( clin* or intervention* or compar* or experiment* or therapeutic ) or AB ( clin* or intervention* or compar* or experiment* or therapeutic ) S33 TI ( cross?over or control* or factorial or sham ) or AB ( cross?over or control* or factorial or sham ) S32 S30 and S31 S31 TI ( blind* or mask* ) or AB ( blind* or mask* ) S30 TI ( singl* or doubl* or tripl* or trebl* ) or AB ( singl* or doubl* or tripl* or trebl* ) S29 TI random* or AB random* S28 PT clinical trial S27 (MH "Clinical Research") OR (MH "Clinical Nursing Research") S26 (MH "Nonrandomized Trials") OR (MH "Study Design") OR (MH "Community Trials") OR (MH "One‐Shot Case Study") OR (MH "Experimental Studies") OR (MH "Pretest‐Posttest Design") OR (MH "Solomon Four‐Group Design") OR (MH "Static Group Comparison") S25 (MH "Quasi‐Experimental Studies") S24 (MH "Factorial Design") S23 (MH "Control (Research)") OR (MH "Control Group") S22 (MH "Comparative Studies") S21 (MH "Clinical Trials+") S20 (MH "Crossover Design") S19 (MH "Random Sample") OR (MH "Random Assignment") S18 S16 or S17 S17 (MH "Language Disorders/RH/TH") OR (MH "Aphasia/RH/TH") OR (MH "Aphasia, Broca/RH/TH") OR (MH "Aphasia, Wernicke/RH/TH") S16 S7 and S15 S15 S8 or S9 or S10 or S11 or S14 S14 S12 and S13 S13 TI ( therap* or train* or rehabilitat* or treat* or pathol* ) or AB ( therap* or train* or rehabilitat* or treat* or pathol* ) S12 TI ( speech or language or aphasia or dysphasia ) or AB ( speech or language or aphasia or dysphasia ) S11 (MH "Speech‐Language Pathologists") S10 (MH "Communication Skills Training") S9 (MH "Speech‐Language Pathology") S8 (MH "Rehabilitation, Speech and Language") OR (MH "Alternative and Augmentative Communication") OR (MH "Language Therapy") OR (MH "Speech, Alaryngeal+") OR (MH "Speech Therapy") S7 S1 or S2 or S3 or S6 S6 S4 and S5 S5 TI ( disorder* or impair* or problem* or dysfunction ) or AB ( disorder* or impair* or problem* or dysfunction ) S4 TI ( language or linguistic ) or AB ( language or linguistic ) S3 TI ( aphasi* or dysphasi* or anomia or anomic ) or AB ( aphasi* or dysphasi* or anomia or anomic ) S2 (MH "Language Disorders") S1 (MH "Aphasia") OR (MH "Aphasia, Broca") OR (MH "Aphasia, Wernicke")

New search for studies and content updated (conclusions changed)

Data and analyses

Comparison 1.

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Comparison 1 SLT versus no SLT, Outcome 15 Adherence to allocated intervention.

Comparison 2

Comparison 3, comparison 4.

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Comparison 4 High‐ versus low‐intensity SLT, Outcome 11 Adherence to allocated intervention.

Comparison 5

Comparison 6, comparison 7, comparison 8, comparison 9.

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Comparison 9 Early versus delayed SLT, Outcome 4 Expressive language: written.

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Comparison 9 Early versus delayed SLT, Outcome 5 Expressive language: repetition.

Comparison 10

Comparison 11, comparison 12, comparison 13, comparison 14, comparison 15, comparison 16, comparison 17, comparison 18, comparison 19, comparison 20.

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 2 Expressive language.

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 3 Severity of impairment: Aphasia Battery Score.

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 4 Functional communication (follow‐up).

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Comparison 20 SLT with gestural adjunct versus SLT, Outcome 5 Expressive language: (follow‐up).

Comparison 21

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Comparison 21 Melodic intonation therapy versus other SLT, Outcome 2 Expressive language: naming.

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Comparison 21 Melodic intonation therapy versus other SLT, Outcome 3 Expressive language: repetition.

Comparison 22

Comparison 23.

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Comparison 23 Operant training SLT versus conventional SLT, Outcome 2 Receptive language: other.

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Comparison 23 Operant training SLT versus conventional SLT, Outcome 3 Expressive language: spoken.

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Comparison 23 Operant training SLT versus conventional SLT, Outcome 4 Expressive language: written.

Comparison 24

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Comparison 24 Verb comprehension SLT versus preposition comprehension SLT, Outcome 2 Receptive language: reading.

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Comparison 24 Verb comprehension SLT versus preposition comprehension SLT, Outcome 3 Expressive language.

Comparison 25

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Comparison 25 Discourse therapy versus conventional therapy, Outcome 2 Receptive language: word comprehension.

Comparison 26

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 2 Expressive language: spoken sentence.

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 3 Expressive language: naming.

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 4 Expressive language: naming (follow‐up).

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Comparison 26 'Task Specific' production versus conventional therapy, Outcome 5 Expressive language: spoken sentence.

Comparison 27

Comparison 28.

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 2 Receptive language: word comprehension.

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 3 Receptive language: other auditory comprehension.

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 4 Receptive language: auditory comprehension (treated items).

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 5 Receptive language: reading comprehension.

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Comparison 28 Auditory comprehension SLT versus conventional SLT, Outcome 6 Expressive language: naming.

Comparison 29

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Comparison 29 FIlmed programme instruction versus conventional SLT, Outcome 2 Receptive language: reading comprehension.

Characteristics of studies

Characteristics of included studies [ordered by study id].

AAC : Alternative and Augmentative Communication; AAT : Aachen Aphasia Test; ACTS : Auditory Comprehension Test for Sentences; ADL : activities of daily living; AMERIND :American Indian, a general communication system; ANELT : Amsterdam‐Nijmegen Everyday Language Test; AQ : Aphasia Quotient; BDAE : Boston Diagnostic Aphasia Examination; CADL :Communication Abilities of Daily Living; CETI : Communicative Effectiveness Index; CFCP : Chinese Functional Communication Profile; CHSPT : Caplan and Hanna Sentence Production Test; CIAT : constraint‐induced aphasia therapy; CMA : Canadian Medical Association; CRRCAE : Chinese Rehabilitation Research Centre Aphasia Examination; CT : computerised tomography; CVA : cerebrovascular accident; DA : discourse analysis; dB : decibels; FAST : Frenchay Aphasia Screening Test; FCP : FunctionalCommunication Profile; FE scale : Functional‐Expression scale; GCS : Glasgow coma scale; GHQ : general health questionnaire; GP : general practitioner; ITT : intention‐to‐treat; MAACL : Multiple Adjective AffectCheck‐List; MCA : middle cerebral artery; MDT : multidisciplinary team; MRI : magnetic resonance imaging; MTDDA : Minnesota Test for the Differential Diagnosis of Aphasia; NGA : Norsk Grunntest for Afasi; NHP : Nottingham Health Profile; NHS : National Health Service (UK); NIHSS : National Institutes of Health Stroke Scale; ONT : Object Naming Test; ORLA : Oral Reading for Language in Aphasia; PACE : Promoting Aphasics' Communicative Effectiveness; PALPA : Psycholinguistic Assessments of Language Processing in Aphasia; PCB : Philidelphia Comprehension Battery; Peabody PVT : Peabody Picture Vocabulary Test; PICA : Porch Index of Communicative Abilities; RCBA : Reading Comprehension Battery for Aphasia; RCT : randomised controlled trial; SAQolL : stroke and aphasia quality of life scale; SAT : Semantic Association Test; SD : standard deviation; SLT : speech and language therapy; SPICA : Shortened Porch Index of Communicative Abilities; STACDAP : Systematic Therapy for Auditory Comprehension Disorders in Aphasic Patients; TACS : Texas Aphasia Contrastive‐Language Series; TOMs : Therapy Outcomes Measures; WAB : Western Aphasia Battery; WAIS : Wechsler Adult Intelligence Scale.

Characteristics of excluded studies [ordered by study ID]

RCT : randomised controlled trial; SLT : speech and language therapy; TBI : traumatic brian injury.

Characteristics of studies awaiting assessment [ordered by study ID]

AAT : Aachen Aphasia Test; SLT : speech and language therapy; WAB : Western Aphasia Battery.

Characteristics of ongoing studies [ordered by study ID]

ABC : Aphasia Battery in Chinese; ADL : activities of daily living; ANELT : Amsterdam‐Nijmegen Everyday Language Test; AQ : Aphasia Quotient; BDAE : Boston Diagnostic Aphasia Examination; BNT : Boston Naming Test; CAT : Comprehensive Aphasia Test; CCRE : Centre for Clinical Research Excellence; CETI : Communicative Effectiveness Index; CIAT : constraint‐induced aphasia therapy; CIU : correct information unit; CT : computerised tomography; CVA : cerebrovascular accident; DTI : diffusion tensor imaging; FCP : Functional Communication Profile; fMRI : functional magnetic resonance imaging; NHS : National Health Service (UK); MCA : middle cerebral artery; MIT : melodic intonation therapy; MRI : magnetic resonance imaging; PALPA : Psycholinguistic Assessments of Language Processing in Aphasia; PACE : Promoting Aphasics' Communicative Effectiveness therapy; PGI : Patient Global Impression; RCT : randomised controlled trial; SAH : subarachnoid haemorrhage; SAQoL : Stroke and Aphasia Quality of Life Scale; SAT : Semantic Association Test; SDH : subdural haematoma; SLT : speech and language therapy; TIA : transient ischaemic attack; TOMs : Therapy Outcome Measures; UAT : unconstrained aphasia therapy; WAB : Western Aphasia Battery; WBIC : Wolfson Brain Imaging Centre.

Differences between protocol and review

Amendments to the original 1999 review.

Following close inspection of the original review and detailed discussion among this review team ( Greener 1999 ), we made adjustments to the review, many of which reflect changes in Cochrane procedures, review methodologies, and style and structure in the time since the publication of the original review. These amendments were ratified by the Cochrane Stroke Group Editorial Board on 23 November 2006.

We updated the Background section to include a definition of SLT and aphasia, and to reflect current approaches and rationale to SLT interventions and outcomes.

We amended the Objectives to a single statement according to the standard format of Cochrane reviews; that is, to assess the effects of SLT interventions for aphasia following stroke.

It was unclear whether or not quasi‐randomised controlled trials were included in the original review. We have excluded quasi‐randomised trials.

We compressed the Types of interventions into three broad categories: SLT versus no SLT intervention, SLT versus social support or stimulation, and SLT intervention A versus SLT intervention B (where A and B refer to two different types of therapeutic interventions or approaches).

We refined the Types of outcome measures to a single primary outcome measure of functional communication. Secondary outcomes include other measures of communication (receptive or expressive language, or both), psychosocial outcomes, patient satisfaction with the intervention, number of participant dropouts for any reason, adherence to the allocated intervention, economic outcomes (such as cost to the patient, caregivers, families, health service, and society) and caregiver or family satisfaction. We extracted data relating to death, morbidity and cognitive skills in the original review, but on reflection, we did not consider these to be relevant indicators of the effectiveness of an SLT intervention, and we therefore excluded them from this update. The original review reported overall functional status (e.g. Barthel Index) as one of a number of primary outcomes. As described above, we focused on a single primary outcome (in line with the current review methodology).

Data extraction tool

For this 2016 version of the review, PC and MB created and piloted a new electronically based data extraction tool. MB and HK or PE had extracted data from trials included the 2012 review using a paper‐based tool.

Re‐running the original search strategy for the MEDLINE and CINAHL databases raised over 12.6 million references. Therefore, Brenda Thomas, the Cochrane Stroke Group Trials Search Co‐ordinator, devised up‐to‐date search strategies. We handsearched the International Journal of Language and Communication Disorders (previously named the British Journal of Disorders of Communication , the European Journal of Disorders of Communication and the International Journal of Disorders of Communication) from 1969 to 2005. This journal has been indexed by MEDLINE since 2006 and was thus included in our electronic searches from this date.

The original 1999 review listed studies other than identified RCTs in the Characteristics of excluded studies table, including single case or case series studies. As there are a vast number of such studies, the updated table now only presents potentially relevant studies that appear to be randomised but which we excluded for other reasons (e.g. quasi‐randomised or where we could not extract aphasia‐specific data).

Comparisons

Mid‐trial outcome scores were included in the 1999 review. We have focused our reporting on postintervention and follow‐up scores. We have not included analyses of the number of participants who deteriorated on particular outcome measures.

Other amendments

As we were unable to obtain the extraction sheets for the trials included in the review (published in 1999), we cross‐checked the data extracted for the original review with the available published and unpublished data. We made some amendments regarding the exclusion of some studies and the categorisation of the methods of allocation concealment used in the included trials.

In the 2012 review update, we excluded quasi‐randomised studies, so we excluded one study that had contributed to the 1999 review ( Hartman 1987 ). In addition, on reviewing the data from another trial ( Kinsey 1986 ), we decided that the reported comparison was not a therapy intervention as such, but rather a comparison of task performance (computer‐based or with a therapist). We thus excluded this trial from subsequent reviews. The review team considered allocation concealment for one study to be 'inadequate' in the 1999 review ( MacKay 1988 ). We failed to get confirmation of the method of allocation from the authors, and therefore we amended the allocation for this trial to 'unclear'. The 1999 review included a matched control group of no SLT intervention for one trial ( Prins 1989 ). However, unlike the other groups in this trial, this group was not randomised, therefore we have excluded it from this update. Another study had been excluded from the original review on the grounds that it was not an RCT ( Shewan 1984 ). Discussion with the trialists has since revealed that it was, and we have now included it in the 2012 and 2016 reviews.The original 1999 review included outcomes relating to the impact of SLT on the emotional well‐being of family members ( Lincoln 1984a ). Such outcomes do not directly relate to the aims of this review, so we have not included these measures.

Information added to the 1999 review

Following an extensive search up to April 2009, we identified an additional 20 trials as suitable for inclusion in the review. The 2010 review included data from 30 trials involving 1840 randomised participants ( Kelly 2010 ).

Information added to the 2012 review

Following an extensive search from inception of the electronic databases up to July 2011, we identified an additional nine trials eligible for inclusion in the review. This 2012 review update now includes data from 39 trials involving 2518 randomised participants.

Information added to the 2016 review

Following a revised and extended search (incorporating additional electronic databases) from inception of the databases up to 22 September 2015, we identified an additional 18 trials (22 randomised comparisons) eligible for inclusion in the review. This 2016 review update now includes data from 57 completed trials (74 randomised comparisons) involving 3002 randomised participants.

Contributions of authors

MB designed the review, conducted the search, screened and retrieved references for inclusion and exclusion criteria, contacted relevant authors, obtained translations for non‐English publications, obtained unpublished data, extracted data from included trials, evaluated methodological quality, entered and analysed the data, interpreted the findings, and wrote the review.

HK conducted an early version of the search (1999 to 2009) and screened and retrieved references for inclusion and exclusion criteria, contacted relevant authors and academic institutions, obtained translations for non‐English publications, obtained unpublished data, extracted data from included trials, evaluated methodological quality, entered and analysed data, interpreted the findings, and contributed to the writing of the review.

JG provided statistical support for data extraction and analysis and commented on review drafts.

PE co‐authored the original review, contributed to the evaluation of the methodological quality and interpretation of certain studies, and commented on the updated review .

PC conducted the new search (for the 2015 review), screened and retrieved references for inclusion and exclusion criteria, obtained translations for non‐English publications, obtained unpublished data, extracted data from included trials, evaluated methodological quality, entered the data, interpreted the findings, and wrote the review.

Sources of support

Internal sources.

Nursing, Midwifery and Allied Health Professions Research Unit, UK.

External sources

Chief Scientist Office Scotland, UK.

Declarations of interest

Marian Brady is a speech and language therapist, member of the Royal College of Speech and Language Therapists, and is registered with the Health and Care Professions Council, UK.

Helen Kelly is a speech and language therapist and member of the Royal College of Speech and Language Therapists.

Pam Enderby has been involved in two studies included in this review. She did not contribute to the assessment or interpretation of either of these studies.

Jon Godwin: none known.

Pauline Campbell: none known.

References to studies included in this review

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Laska 2011 {published and unpublished data}.

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Lincoln 1982i {published and unpublished data}

Lincoln NB. An Investigation of the Effectiveness of Language Retraining Methods with Aphasic Stroke Patients. [PhD thesis] . London, UK: University of London, 1980. [ Google Scholar ]
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Lincoln NB. An Investigation of the Effectiveness of Language Retraining Methods with Aphasic Stroke Patients. [PhD thesis] . 1980. [ Google Scholar ]

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Lincoln 1984a {published and unpublished data}.

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Lincoln NB. An Investigation of the Effectiveness of Language Retraining Methods with Aphasic Stroke Patients . [PhD thesis] 1980.
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Lyon 1997 {published and unpublished data}

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Meikle M, Wechsler E, Tupper A, Benenson M, Butler J, Mulhall D, et al. Comparative trial of volunteer and professional treatments of dysphasia after stroke . BMJ 1979; 2 ( 6182 ):87‐9. [ PMC free article ] [ PubMed ] [ Google Scholar ]

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MIT 2014ii {published and unpublished data}

Narnia 2013 {published data only}.

ACTRN12613001263785. For people with aphasia following stroke, is a manualised narrative intervention programme aimed at improving discourse in everyday communication situations more effective than usual speech pathology intervention as measured by improved language ability across the different levels of language (i.e. words, sentences, discourse) in everyday communication activities? . http://www.anzctr.org.au/ACTRN12613001263785.aspx (accessed 22 September 2015). [ACTRN12613001263785]
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ORLA 2006 {published and unpublished data}

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ORLA 2010 {published and unpublished data}

Cherney LR. Oral Reading for Language in Aphasia (ORLA): evaluating the efficacy of computer‐delivered therapy in chronic nonfluent aphasia . Topics in Stroke Rehabilitation 2010; 17 ( 6 ):423‐31. [ PubMed ] [ Google Scholar ]

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Prins RS. Aphasia: classification, treatment and recovery [Afasie: classificatie, behandeling en herstelverloop]. Unpublished doctoral dissertation, University of Amsterdam 1987.
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RATS {published and unpublished data}

Doesborgh SJC, Sandt‐Koenderman MWE, Dippel DWJ, Koudstaal PJ, Visch‐Brink EG. Effects of semantic treatment on verbal communication and linguistic processing in aphasia after stroke: a randomized controlled trial . Stroke 2004; 35 ( 1 ):141‐6. [ PubMed ] [ Google Scholar ]
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RATS‐2 {published and unpublished data}

Jong‐Hagelstein M. Word Finding Deficits in Aphasia: Diagnosis and Treatment [PhD thesis] . Rotterdam: Erasmus Universiteit, 2011. [ Google Scholar ]
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SEMaFORE {published and unpublished data}

Morris J. SemaFoRe: Semantic feature & Repetition therapy in aphasia: a pilot RCT . www.ukctg.nihr.ac.uk/trials?query=%257B%2522query%2522%253A%2522semafore%2522%257D (accessed 22 September 2015).

Shewan 1984i {published and unpublished data}

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Shewan 1984ii {published and unpublished data}

Shewan 1984iii {published and unpublished data}, sickert 2014 {published data only}.

NCT01625676. Constraint‐induced aphasia therapy following sub‐acute stroke: a modified therapy schedule . http://clinicaltrials.gov/show/NCT01625676 (accessed 22 September 2015). [NCT01625676]
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Smith 1981ii {published and unpublished data}

Smith 1981iii {published and unpublished data}, sp‐i‐rit {published and unpublished data}.

Lauterbach M, Leal G, Aguiar M, Fonseca I, Farrajota L, Fonseca J, et al. Intensive vs conventional speech therapy in aphasia due to ischaemic stroke: a randomized controlled trial . Proceedings of the British Aphasiology Society Biennial International Conference Sept 10‐12 2007; Edinburgh, UK . UK: British Aphasiology Society, 2007:67‐8.
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Van Steenbrugge 1981 {published and unpublished data}

Steenbrugge WJ, Prins RS. Word finding difficulties and efficacy of systematic language therapy in aphasic patients . Logopedie en Foniatrie 1981; 53 :622‐37. [ Google Scholar ]

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Varley R, Cowell PE, Dyson L, Inglis L, Roper A, Whiteside SP. Self‐administered computer therapy for apraxia of speech: two‐period randomized control trial with crossover . Stroke 2016; 47 ( 3 ):822‐8. [ PubMed ] [ Google Scholar ]
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VERSE I {published and unpublished data}

Godecke E, Ciccone N, Granger A, Hankey G, West D, Cream A, et al. Aphasia therapy in early stroke recovery . International Journal of Stroke 2011; 6 ( Issue supplement 1 ):12. [ Google Scholar ]
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VERSE II {unpublished data only}

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Wertz 1981 {published and unpublished data}

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Kurtzke JF, Wertz RT, Weiss DG, Garcia‐Bunuel L, Aten JL, Brookshire RH, et al. Comparison of improvement in neurologic severity and language in treated and untreated aphasic patients . Neurology 1985; 35 ( Suppl 1 ):122. [ Google Scholar ]
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Wertz 1986ii {published and unpublished data}

Wertz 1986iii {published and unpublished data}.

Kurtzke JF, Wertz RT, Weiss DG, Garcia‐Bunuel L, Aten JL, Brookshire RH, et al. Comparison of Improvement in neurologic severity and language in treated and untreated aphasic patients . Neurology 1985; 35 ( Suppl 1 ):122. [ Google Scholar ]

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Woolf 2015i {published and unpublished data}

Woolf C, Caute A, Haigh Z, Galliers J, Wilson S, Kessie A, et al. A comparison of remote therapy, face to face therapy and an attention control intervention for people with aphasia: a quasi‐randomised controlled feasibility study . Clinical Rehabilitation 2016; 30 ( 4 ):359‐73. [ PubMed ] [ Google Scholar ]

Woolf 2015ii {published data only}

Woolf 2015iii {published data only}, wu 2004 {published data only (unpublished sought but not used)}.

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Yao 2005iii {published data only (unpublished sought but not used)}, zhang 2007i {published data only}.

Zhang H‐M. Clinical treatment of apoplectic aphemia with multi‐needle puncture of scalp‐points in combination with visual‐listening‐speech training . Zhenci Yanjiu [Acupuncture Research] 2007; 32 ( 3 ):190‐4. Chinese. [ PubMed ] [ Google Scholar ]

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Zhao 2000 {published data only (unpublished sought but not used)}.

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Cherney 2010 {published data only}

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Cherney 2011 {published data only}

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ACTRN12614000979651. In stroke patients with aphasia and their caregivers does the Aphasia ASK Action Success Knowledge (ASK) program, compared to an attention control package, promote better mood and overall quality of life outcomes . http://www.anzctr.org.au/ACTRN12614000979651.aspx (accessed 22 September 2015). [ACTRN12614000979651]

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COMPARE {published and unpublished data}

Rose M, Attard M, Mok Z, Lanyon L, Foster A. Multi‐modality aphasia therapy is as efficacious as a constraint‐induced aphasia therapy for chronic aphasia: a phase 1 study . Aphasiology 2013; 27 ( 8 ):938‐71. [ Google Scholar ]
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Lee J, Fowler R, Rodney D, Cherney L, Small SL. IMITATE: An intensive computer‐based treatment for aphasia based on action observation and imitation . Aphasiology 2010; 24 ( 4 ):449‐65. [ PMC free article ] [ PubMed ] [ Google Scholar ]
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NCT02012374. Overcoming learned non‐use in chronic aphasia: behavioral, fMRI and QoL outcomes . http://clinicaltrials.gov/show/NCT02012374 (accessed 22 September 2015). [NCT02012374]

LIFT 2014 {published and unpublished data}

ACTRN12613001182785. Can a new intensive model of aphasia rehabilitation achieve better outcomes than usual care with chronic aphasia resulting from stroke? . https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364926 (accessed 22 September 2015). [ACTRN12613001182785]
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ORLA‐Write {published data only}

NCT01790880. Enhancing written communication in persons with aphasia: a clinical trial . http://clinicaltrials.gov/show/NCT01790880 (accessed 22 September 2015).

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RATS‐3 {unpublished data only}

NTR3271. Rotterdam Aphasia Therapy Study‐3: The efficacy of early, intensive cognitive‐linguistic therapy in aphasia after stroke (a randomized controlled trial). ‐ RATS‐3 . http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3271 (accessed 26 November 2014).
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TNT ‐ ACTRN12614000081617 {published data only}

ACTRN12614000081617. Tablets and technology during stroke recovery . https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365227&isClinicalTrial=False (accessed 22 September 2015).

U‐Health {published data only}

NCT01815905. U‐Health service using mobile device for improvement of post‐stroke upper limb function and aphasia . http://clinicaltrials.gov/show/NCT01815905 (accessed 22 September 2015).

VERSE III {published data only}

ACTRN12613000776707. A three armed, prospective multicentre randomised controlled speech therapy trial comparing usual care, usual care plus and Very Early Rehabilitation in Speech (VERSE) with blinded outcome assessment of the Aphasia Quotient score in patients with aphasia following acute stroke . Australian New Zealand Clinical Trials Registry (accessed 26 November 2014).
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Collaborative working in speech and language therapy for children with DLD-What are parents' needs?

Affiliations.

1 Research Center for Healthy and Sustainable Living, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands.
2 Institute for Language Sciences, Utrecht University, Utrecht, The Netherlands.
3 Department of Education, University Medical Centre Utrecht, Utrecht, The Netherlands.
4 Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.
5 De Hoogstraat Rehabilitation, Utrecht, The Netherlands.
PMID: 37715545
DOI: 10.1111/1460-6984.12951

Background: Collaborative practice between therapists and parents is a key element of family-centred care and is essential if we want to address family priorities and needs in interventions. However, collaborative practice is challenging for speech and language therapists (SLTs) and parents. To facilitate collaboration, collaborative practices need to be implemented into speech and language therapy for young children with developmental language disorders (DLD) and their families. Actual change and implementation of collaboration in practice will be successful only when it corresponds with patients' needs, in our case the needs of parents of young children with DLD.

Aims: To explore parents' needs in their collaboration with SLTs during therapy for their young child with DLD.

Methods & procedures: Parents of children with (a risk of) DLD in the age of 2-6 years were eligible for participation. We recruited parents via SLTs. Twelve parents of children with DLD participated in semi-structured interviews about their needs in collaboration with SLTs. We used a phenomenological approach focusing on parents' lived experiences. We transcribed the interviews verbatim. All interviews were read/listened to and discussed by our parent panel, multiple researchers and the interviewer. Two researchers independently analysed the data using the reflective thematic analysis of Braun and Clarke.

Outcomes & results: The analysis of the interviews resulted in six themes: (1) knowing what to expect, (2) knowing how to contribute, (3) feeling capable of supporting the child, (4) trusting the therapist, (5) alignment with parents and children's needs, preferences and priorities and (6) time and space for asking questions and sharing information.

Conclusions & implications: Parents want SLTs to invest time in collaborating with them. Parents need SLTs to empower them to become a collaborative partner and enable them to support their child in daily life. Parents need knowledge about the therapy process and diagnosis and skills in how to support their child's language development. Also, they need emotional support to feel secure enough to support their child, to ask questions to therapists and to bring up their own thoughts and opinions in therapy. Parents' needs are in line with collaborative working as described in literature, which underlines the importance of implementing collaborative working in speech and language therapy for young children with DLD.

What this paper adds: What is already known on the subject Several reviews have explored parents' perspectives on speech and language therapy. Results reveal parents' experiences with speech and language therapy in general, and parents' perspectives on specific topics such as shared decision-making and parents/therapists roles in therapy. What this study adds This study adds insights into parents' needs to ensure collaboration with speech and language therapists (SLTs). Parents of young children with developmental language disorders (DLD) need SLTs to invest time to create optimal collaboration. It is important for parents to have enough knowledge about DLD and the SLT process, skills and confidence in how to support their child and opportunities to share thoughts and questions with SLTs. Our results underline the importance of parents being empowered by SLTs to become a collaborative partner. What are the clinical implications of this work? When children are referred to speech and language therapy, parents often venture into an unknown journey. They need support from SLTs to become a collaborative partner in speech and language therapy. Parents need SLTs to invest time in sharing knowledge, skills and power and align therapy to parents' and child's needs, preferences, priorities and expectations.

Keywords: DLD; collaboration; parents’ needs; speech and language therapy.

Child, Preschool
Language Development Disorders* / psychology
Language Development Disorders* / therapy
Language Therapy* / methods
Parents / psychology
Speech Therapy / methods

Grants and funding

RAAK-MKB10.023/Taskforce for Applied Research SIA (Regieorgaan SIA)

Case report
Open access
Published: 12 May 2024

Endovascular treatment in Danon disease: a case report

Rayco Jiménez-Bolaños 1 ,
Francisco Hernández-Fernández ORCID: orcid.org/0000-0001-6681-2683 2 ,
Jorge García-García 2 ,
Óscar Ayo-Martín 2 ,
Laura del Rey Megias 3 ,
Juan David Molina-Nuevo 4 &
Tomás Segura 2 , 5

Journal of Medical Case Reports volume 18 , Article number: 244 ( 2024 ) Cite this article

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Danon disease is a lysosomal storage disorder with X-linked inheritance. The classic triad is severe hypertrophic cardiomyopathy, myopathy, and intellectual disability, with different phenotypes between both genders. Ischemic stroke is an uncommon complication, mostly cardioembolic, related to intraventricular thrombus or atrial fibrillation, among others.

We report the case of a 14-year-old Caucasian male patient with Danon disease who suffered from an acute ischemic stroke due to occlusion in the M1 segment of the middle cerebral artery. He underwent mechanical thrombectomy, resulting in successful revascularization with satisfactory clinical outcome. We objectified the intraventricular thrombus in the absence of arrhythmic events.

To our knowledge, we report the first case of ischemic stroke related to Danon disease treated with endovascular treatment.

Peer Review reports

Danon disease (DD) is a lysosomal storage disorder caused by the mutation of the Lysosomal Associated Membrane Protein 2 ( LAMP-2 ) gene. The exact LAMP-2 protein functions are unknown; however, it seems to play an important role in autophagy [ 1 ]. Its inheritance is X-linked dominant, located in Xq24, with more than 20 mutations described. Severe cardiomyopathy and myopathy are typical features, commonly associated with mental disability. Nevertheless, isolated cardiomyopathy is not infrequent [ 2 ]. Generally, men develop symptoms earlier and more intensely than women [ 3 ]. The prevalence of DD is unknown, but it is estimated at 0.7% of adult patients with hypertrophic cardiomyopathy (HCM) [ 7 ]. To date, approximately 500 cases have been described [ 3 ].

Early morbidity and mortality due to heart failure are known to occur in DD. Furthermore, cardioembolic complications may be relatively common in these patients even with normal systolic function. Indeed, one of the more devastating complications in the natural evolution of patients with DD is the onset of an ischemic stroke secondary to atrial fibrillation (AF) [ 4 ] or intracardiac thrombi, located in the left ventricle [ 3 , 5 ]. Formation of these thrombi is uncommon in non-metabolic HCM except when associated with severe ventricular dysfunction or AF or Wolff-Parkinson-White (WPW) arrhythmias, which may often occur in patients with DD. There is a lack of research on the management of acute stroke in these patients.

We present the first case of a patient with DD who suffered an acute ischemic stroke and treated with mechanical thrombectomy.

Medical history

An 18-month-old Caucasian boy, with no relevant prenatal, medical, or family history, parents not consanguineous, suffered from delayed motor development, hypotonia, and an increase in creatine-kinase and liver enzymes. The patient developed progressive proximal muscle weakness in both upper and lower limbs with bilateral winged scapula. Electromyography revealed a myopathic pattern. During follow-up at 10 years, after identifying a heart murmur, echocardiography revealed severe global left ventricular hypertrophy, mainly at the intraventricular septum (IVS 14–15 mm), with multiple trabeculae and preserved systolic function. The electrocardiogram showed WPW syndrome. The muscle biopsy reported vacuolar myopathy with autophagic characteristics and glycogen accumulation. The genetic test confirmed the presence of a mutation c.973dup;p (leu325profs25) in the LAMP-2 gene. An implantable cardioverter defibrillator was inserted due to atrioventricular block.

Case history

At the age of 14 years, he experienced speech impairment and right limb weakness upon awakening. Physical examination showed aortic systolic murmur and normal vital signs (blood pressure 116/81 mmHg; heart rate 60 beats per minute; temperature 36 °C). Neurological examination revealed moderate dysarthria, right central facial paresis and ipsilateral hemiparesis, right Babinski reflex and left brachial hypesthesia. The National Institute of Health Stroke Scale (NIHSS) score was 9.

Diagnostic investigations and endovascular procedure

A head computed tomography (CT) scan and CT angiogram demonstrated an Alberta Stroke Program Early CT Score (ASPECTS) of 10 and a complete occlusion of the left middle cerebral artery (MCA) bifurcation. A CT-perfusion study showed a large area of long mean transit time (MTT) with complete conservation of cerebral blood volume (CBV) in the left frontal-parietal-temporal territory. According to the local ischemic stroke protocol, the patient met the criteria for mechanical thrombectomy, except for age (less than 18 years) and DD. Therefore, due to excellent prognostic factors (ASPECTS 10 and favorable mismatch), emergent primary endovascular treatment was decided upon after informing the parents. Mechanical thrombectomy was performed using stent retriever with complete flow restoration (TICI 3) in one pass (Fig. 1 A).

A Cerebral angiography during procedure demonstrating a complete occlusion of the left middle cerebral artery bifurcation. B Echocardiogram revealed a hypertrophic cardiomyopathy and an echogenic mass at the left ventricular apex suggestive of intracardiac thrombus

Post-procedure care and etiological evaluation

The patient was admitted to the stroke unit and became asymptomatic 24 hours post-procedure (NIHSS 0). The CT scan evidenced hypo-attenuation of left caudate and lentiform nuclei and anterior limb of internal capsule. An etiological assessment was performed and an echocardiogram revealed worsening of the left ventricular hypertrophy (IVS 30–35 mm) showing an echogenic mass at the left ventricular apex suggestive of intracardiac thrombus (Fig. 1 B), secondary to heart disease previously observed during follow-up. The laboratory findings showed an increased in creatine-kinase (CK 1596 μmol/l) and liver enzymes glutamate pyruvate alanine aminotransferase (GPT 274 U/L), similar to previous values, without other alterations (glucose 106 mg/dL; urea 25 mg/dL; creatinine 0.62 mg/dL; sodium 141 mEq/L; potassium 4 mEq/L; chlorine 103 mEq/L). Urinary sediment analysis and toxin screen were negative. The coagulation test was normal, including international normalized ratio (INR) 1.36. We initiated low-molecular weight heparin (enoxaparin 60 mg/12 hours) for 15 days as bridging therapy despite the determination of a factor VII deficiency. Subsequently, we replaced apixaban 5 mg/12 hours instead of vitamin-K antagonist due to high bleeding risk. On discharge, the patient had completely recovered to his prior neurological state, which included winged scapulae and waddling gait. The patient remained asymptomatic during the 6-month follow-up and the apical thrombus disappeared.

Discussion and conclusions

DD may be a rare cause of ischemic stroke due to a cardioembolic mechanism, even in those with normal systolic function. In selected cases based on the main criteria, endovascular treatment may be an effective therapeutic strategy to prevent disability in patients with large-vessel-occlusion ischemic stroke, but further research is needed to improve upon knowledge.

DD is a rare multisystem disorder characterized by the triad of HCM, skeletal myopathy and intellectual disability. Cardiac involvement typically described is HCM; nevertheless, dilated cardiomyopathy has also been reported, mainly in women [ 2 ]. The X-linked dominant inheritance involves differences in clinical severity between both genders. Women usually develop a milder clinical phenotype, and occasionally only have heart disease, which can be as serious as in men [ 3 ]. Women usually develop a milder clinical phenotype, though with an exclusive cardiac involvement with similar damage.

DD prevalence is unknown. Around 500 cases have been reported worldwide since it was first described first in 1981 [ 3 ]. Many patients develop ischemic stroke, frequently at younger ages and with unfavorable prognosis. No endovascular treatment in acute event has been informed [ 3 ].

In 2008, Spinazzi et al . described three patients (two men and one woman) with severe HCM and AF who suffered from ischemic stroke [ 4 ]. In 2016, Marino et al . described a patient with hemodynamic ischemic stroke following cardiac arrest secondary to WPW [ 6 ]. In 2017, Takeshi et al . described a patient with ischemic stroke secondary to intracardiac thrombus [ 5 ]. Embolic stroke from the heart is common in DD and is associated with left ventricular dysfunction, older age, AF, or congestive heart failure [ 4 ]. Intracardiac thrombus formation is very rare in HCM, unless associated with very severe left ventricular dysfunction, AF, or WPW syndrome. Early identification of embolic source is relevant for prompt initiation of anticoagulation if indicated [ 3 , 5 ]. In our case, we established the cardioembolic source of the ischemic stroke after demonstrating an intraventricular thrombus on echocardiography.

To our knowledge, we present the first case of an acute ischemic stroke in a patient with DD who received mechanical thrombectomy. We performed the most widely used extraction method, that is, the stent retriever, with excellent angiographic and clinical results.

Therefore, it is reasonable to consider endovascular treatment beneficial in these patients. In addition, it is the most efficient therapeutic tool to prevent disability secondary to ischemic stroke. The development of impairment may contraindicate cardiac transplantation, therefore avoiding disability should be of major importance. Nonetheless, further studies are necessary to confirm our results.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We thank Dr. Javaad Ahmad for the revision of the English translation.

AMIDA, Asociación de Médicos Investigadores de Albacete, Albacete, Spain.

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Department of Neurology, Complejo Hospitalario Universitario Insular-Materno Infantil de Canarias, Las Palmas, Spain

Rayco Jiménez-Bolaños

Department of Neurology, Complejo Hospitalario Universitario de Albacete, C/Hermanos Falcó 37, 02006, Albacete, Spain

Francisco Hernández-Fernández, Jorge García-García, Óscar Ayo-Martín & Tomás Segura

Pediatric Cardiology, Department of Pediatrics, Complejo Hospitalario Universitario de Albacete, Albacete, Spain

Laura del Rey Megias

Department of Radiology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain

Juan David Molina-Nuevo

Institute for Research in Neurologic Disabilities (IDINE), Medical School, University of Castilla-La-Mancha, Albacete, Spain

Tomás Segura

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RJB was responsible for the integrity of the study; FHF, RJB, and JGG for study design; RJM, JDMN, and LDR for data collection; TS and OAM for data analysis and interpretation; NA for statistical treatment; RJB and JGG for bibliographic search; RJB and FHF for writing—manuscript; FHF, TS, and JGG for critical revision of the manuscript with intellectually relevant contributions; and FHF, TS, RJB, OAM, JDMN, LDR, and JGG for approval of the final version:.

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Correspondence to Francisco Hernández-Fernández .

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The authors of the research asked all patients to sign an informed consent prior to undergoing the diaphragmatic ultrasonography. The good clinical practice guidelines and the Declaration of Helsinki were followed. Confidentiality of the data obtained was kept and they were only used for the study purposes. Our clinical research was reviewed and approved by the Clinical Research Ethics committee of the University Hospital Complex of Albacete.

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Jiménez-Bolaños, R., Hernández-Fernández, F., García-García, J. et al. Endovascular treatment in Danon disease: a case report. J Med Case Reports 18 , 244 (2024). https://doi.org/10.1186/s13256-024-04555-7

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Mayo Clinic Q and A: Speech therapy after a stroke
ANSWER: The overall effectiveness of speech therapy for people who have communication difficulties after a stroke largely depends on the area of the brain the stroke affected and the severity of the brain damage. Generally, speech therapy can help those whose speech is affected by a stroke. The most common type of stroke is an ischemic stroke ...
The role of the speech language pathologist in acute stroke
Speech-language pathologists (SLP) play a significant role in the screening, formal assessment, management, and rehabilitation of stroke survivors who present with dysphagia and/or communication impairment. Early diagnosis and referral is critical, as is intensive intervention as soon as the patient is able to participate.
Speech and Language Therapy for Aphasia After Stroke
Meta-analysis of speech and language therapy (SLT) versus no SLT on functional communication, receptive and expressive language, outcomes. ... Future research endeavors should seek to establish the optimum approach, regimen, and delivery of SLT for specific patient groups with aphasia after stroke. Acknowledgments.
Current Approaches to the Treatment of Post-Stroke Aphasia
Behavioral therapy to improve language in stroke aphasia: the basics. By far, the most common approach to aphasia rehabilitation is behavioral speech and language therapy (SLT). SLT was even described by Paul Broca in his seminal 1865 paper , and it remains the standard of care for patients with aphasia .
Rehabilitation of Communication Disorders
The Cochrane review of speech and language therapy for aphasia post-stroke ... Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. Lancet 389:1528-1538. [PubMed: 28256356] Choi Y, Park H, Ahn K et al (2015) A telescreening ...
PDF Complete Guide to Communication Problems After Stroke
8 Communication problems after stroke Speech and language therapy Speech and language therapy helps you to improve your ability to communicate. Research shows that people who have speech and language therapy improve much more than people who don't. Many people think that speech and language therapy is about 'fixing' your problems so
Stroke
Role of speech and language therapy for stroke. The SLT has a key role in: Initial assessment of swallowing and communication difficulties following acute stroke; Training of other healthcare professionals to carry out screening; Long-term rehabilitation of stroke patients as part of the core multidisciplinary stroke rehabilitation team
communication and language
A. People should be assessed early after stroke for communication difficulties by a speech and language therapist to diagnose the problem, devise and implement a treatment programme and explain the nature and implications to the person, their family/carers and the multidisciplinary team. [2023] B. People with aphasia after stroke should be ...
Speech and language therapy for aphasia after a stroke
Overall, the review concluded that for people with aphasia after stroke, their best recovery is associated with: therapy started within 28 days of the onset of aphasia. 20 - 50 hours of speech and language therapy in total. 2 - 4 hours of therapy a week, delivered over 4 - 5 days, for general language improvement. tasks that are practiced ...
Clinical Guidelines for Stroke Management
This living guideline is an update of the 2017 National Stroke Foundation guideline. It provides recommendations for the assessment and management of stroke and transient ischemic attack in adults. Recommendations are intended to help healthcare professionals provide increased quality of stroke care. Management options within the scope of speech-language pathology and audiology are included ...
Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A
A randomized controlled trial on very early speech and language therapy in acute stroke patients with aphasia. Cerebrovasc Dis Extra. 2011; 1:66-74. doi: 10.1159/000329835 Crossref Medline Google Scholar; 39. Lincoln NB. An Investigation of the Effectiveness of Language Retraining Methods With Aphasic Stroke Patients. Ph.D. Thesis.
Recovery
Therapy Often Starts Within 48 hours. Rehabilitation therapy usually first takes place in the hospital within 48 hours of a stroke. It often starts with exercises to help overcome any paralysis or weakness. Recovering the ability to do basic activities of daily living is the first stage in the return to independence after having a stroke.
The Best Speech Therapy Exercises for Stroke Patients
Speech therapy exercises can help individuals improve their ability to communicate and produce language. They can be especially helpful after a neurological injury, such as a stroke. Depending on which area of the brain was affected by stroke, various parts of speech may be affected. Speech therapists can provide personalized exercises focused on helping individuals […]
Full article: Better long-term speech outcomes in stroke survivors who
Patients are supported in providing this information by a speech and language therapist, who facilitates both the patients' understanding of the questions, and their responses, and helps them to differentiate direct language therapy from other typical therapist input delivered during the acute stage post-stroke; e.g., assessment, dysphagia ...
Self-managed, computerised speech and language therapy for patients
People with chronic aphasia post-stroke often want and require more speech and language therapy than they can access. We searched the Cochrane Library and Medline for systematic reviews and randomised controlled trials of interventions or service delivery for chronic aphasia in post-stroke populations, using the search terms "aphasia OR dysphasia AND therapy OR treatment AND stroke".
Speech therapy and the benefits for stroke patients
Speech-language pathologists (SLP) play an integral role in stroke recovery. Our work can be transformative, helping stroke patients recover their speech and with it, freedom of communication. Aphasia, dysarthria, apraxia of speech, and cognition impairments are commonly seen in people recovering from stroke, and can be assessed and treated by SLPs. Additionally, strokes can cause swallowing ...
Guideline adherence in speech and language therapy in stroke aftercare
Background Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients' quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned ...
Language recovery following stroke
As studies began to include more acute stroke patients, however, evidence started to emerge that much of post-stroke language recovery occurred relatively quickly following the initial neurologic insult. ... Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, (4), CD000425. doi: 10.1002/14651858 ...
Intensive speech and language therapy in patients with chronic aphasia
3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke, providing an effective evidence-based treatment approach in this population. Future studies should examine the minimum treatment intensity required for meaningful treatment effects, and determine whether treatment effects cumulate ...
Stroke
Depending upon which type of stroke someone has had, a speech and language therapist will tailor therapy to suit each patients needs. Our speech and language therapists can help individuals who have had a stroke with attention and listening problems, communication problems, swallowing difficulties, voice and speech problems.
Self-managed, computerised speech and language therapy for patients
Background: Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone.
Intensive speech and language therapy in patients with chronic aphasia
In conclusion, FCET2EC is the first multicentre randomised controlled trial in patients with chronic aphasia after stroke to show the superiority of intensive speech and language therapy over treatment deferral (with no or low-intensity treatment). 3 weeks of intensive speech and language therapy of 10 h or more per week in an inpatient or ...
Intensive speech and language therapy in patients with chronic aphasia
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Here are five key things to know about stroke: 1. Strokes affect the oxygen and nutrients supplied to your brain. Strokes occur when nutrients and oxygen are not delivered to the brain through blood vessels, leading to the death of brain cells. This lack of delivery can be caused by a clot in a blood vessel obstructing the blood flow to the ...
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The three-part resource covers the fundamentals of evaluations, interventions, and more based on high-quality evidence. News. Date: Friday, May 10, 2024. Every year, nearly 800,000 people in the U.S. have a stroke, according to the U.S. Centers for Disease Control and Prevention. What do physical therapists and physical therapist assistants ...
Speech and language therapy for aphasia following stroke
Speech and language therapy for language problems after a stroke. Review question. We reviewed the evidence of the effect of speech and language therapy (SLT) on language problems experienced by people after a stroke (known as aphasia). Background. About a third of people who suffer a stroke develop aphasia.
Collaborative working in speech and language therapy for ...
Parents need knowledge about the therapy process and diagnosis and skills in how to support their child's language development. Also, they need emotional support to feel secure enough to support their child, to ask questions to therapists and to bring up their own thoughts and opinions in therapy. Parents' needs are in line with collaborative ...
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speech impairment long-term disability in the United States, stroke affects more than 795,000 individuals each year, including 610,000 initial strokes and ... For post-stroke patients, rehabilitation exercises consist primarily of resistance exercises, aerobic ... imagery combined with structured progressive circuit class therapy on gait in ...
Endovascular treatment in Danon disease: a case report
Background Danon disease is a lysosomal storage disorder with X-linked inheritance. The classic triad is severe hypertrophic cardiomyopathy, myopathy, and intellectual disability, with different phenotypes between both genders. Ischemic stroke is an uncommon complication, mostly cardioembolic, related to intraventricular thrombus or atrial fibrillation, among others. Case report We report the ...
Speech and Language Therapist-Glasgow Community Stroke Team
The multi-disciplinary team includes Speech and Language Therapy, Occupational Therapy, Physiotherapy, Stroke Nurse Specialist, Assistant Practitioner, alongside Stroke Clinical Psychology. We aim to offer a high quality multi-disciplinary team approach to providing stroke rehabilitation in our patient's homes, focused around the achievement ...