Psychological effects of speech therapy

A systematic review of non-drug interventions to prevent and treat anxiety in people with aphasia after stroke

PURPOSE

To investigate the effectiveness of non-drug interventions for people with aphasia in the prevention and/or treatment of anxiety post-stroke as either a primary or secondary outcome.

MATERIALS AND METHODS

A systematic search of Medline, CINAHL, PsycINFO and Cochrane Library up to March 2021 was carried out. Studies of stroke populations were included if people with aphasia represented 25% or more of the enrolled participants. Quality of the evidence was assessed. A narrative synthesis of results is presented. The PROSPERO record ID for this study is 106451.

RESULTS

Ten studies were included: five randomised controlled trials (RCTs), a single case experimental design, and four pre-post studies. The quality of the RCT trials was at least adequate but none demonstrated a benefit to anxiety outcomes. Those studies that reported benefit were of lower-level evidence with respect to National Health and Medical Research Classifications. No studies were found that evaluated the prevention of anxiety after stroke for people with aphasia.

CONCLUSION

Definitive conclusions about the effectiveness of non-drug interventions for the prevention and/or treatment of anxiety in people with aphasia post-stroke cannot be made. Interventions that may show promise for those with aphasia and symptoms of anxiety include mindfulness meditation, modified cognitive behaviour therapy, unilateral nostril breathing, and the "Enhance Psychological Coping after Stroke" programme. Further high-quality research with better reporting of the inclusion of participants with aphasia and their specific sub-group results are required.Implications for RehabilitationIt is important for rehabilitation professionals to consider prevention of anxiety post-stroke as well as treatment.Mindfulness meditation, modified cognitive behavioural therapy, unilateral nostril breathing, and the and the "Enhance Psychological Coping after Stroke" programme may be of benefit to people with aphasia post-stroke.Adapting intervention protocols to be more communicatively accessible and training health professionals in supported communication may help people with aphasia engage in psychological therapies.

A systematic review of rehabilitation interventions to prevent and treat depression in post-stroke aphasia

PURPOSE

Stepped psychological care is the delivery of routine assessment and interventions for psychological problems, including depression. The aim of this systematic review was to analyze and synthesize the evidence of rehabilitation interventions to prevent and treat depression in post-stroke aphasia and adapt the best evidence within a stepped psychological care framework.

METHOD

Four databases were systematically searched up to March 2017: Medline, CINAHL, PsycINFO and The Cochrane Library.

RESULTS

Forty-five studies met inclusion and exclusion criteria. Level of evidence, methodological quality and results were assessed. People with aphasia with mild depression may benefit from psychosocial-type treatments (based on 3 level ii studies with small to medium effect sizes). For those without depression, mood may be enhanced through participation in a range of interventions (based on 4 level ii studies; 1 level iii-3 study and 6 level iv studies). It is not clear which interventions may prevent depression in post-stroke aphasia. No evidence was found for the treatment of moderate to severe depression in post-stroke aphasia.

CONCLUSIONS

This study found some interventions that may improve depression outcomes for those with mild depression or without depression in post-stroke aphasia. Future research is needed to address methodological limitations and evaluate and support the translation of stepped psychological care across the continuum. Implications for Rehabilitation Stepped psychological care after stroke is a framework with levels 1 to 4 which can be used to prevent and treat depression for people with aphasia. A range of rehabilitation interventions may be beneficial to mood at level 1 for people without clinically significant depression (e.g., goal setting and achievement, psychosocial support, communication partner training and narrative therapy). People with mild symptoms of depression may benefit from interventions at level 2 (e.g., behavioral therapy, psychosocial support and problem solving). People with moderate to severe symptoms of depression require specialist mental health/behavioral services in collaboration with stroke care at levels 3 and 4 of stepped psychological care.

Improving social outcome after stroke: an evaluation of the volunteer stroke scheme

Data were obtained on all referrals of stroke patients to the speech therapy departments of two adjoining Health Authorities, Leeds West and Leeds East. Only Leeds West had a Volunteer Stroke Scheme (VSS) available. Qualified speech and language therapists in both Health Authorities classified patients as dysphasic and/or dysarthric and identified those they thought likely to benefit from support from the VSS. From these latter patients, three groups were identified: Leeds West patients receiving support from the VSS ( n = 34); Leeds West patients who refused VSS support ( n = 9); and Leeds East patients with no VSS support available ( n = 10).

All patients were followed up for one year and changes in Barthel Index, Frenchay Activities Index (FAI) and carers' Hospital Anxiety and Depression scores were recorded. Only those patients who received VSS support demonstrated a statistically significant increase in FAI over the year.

Speech and language therapy for aphasia following stroke

BACKGROUND

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.

OBJECTIVES

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.

Speech and language therapy for aphasia following stroke

BACKGROUND

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.

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched June 2011), MEDLINE (1966 to July 2011) and CINAHL (1982 to July 2011). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles and 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) with (1) no SLT; (2) social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); and (3) another SLT intervention (which differed 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 39 RCTs (51 randomised comparisons) involving 2518 participants in this review. Nineteen randomised comparisons (1414 participants) compared SLT with no SLT where SLT resulted in significant benefits to patients' functional communication (standardised mean difference (SMD) 0.30, 95% CI 0.08 to 0.52, P = 0.008), receptive and expressive language. Seven randomised comparisons (432 participants) compared SLT with social support and stimulation but found no evidence of a difference in functional communication. Twenty-five randomised comparisons (910 participants) compared two approaches to SLT. There was no indication of a difference in functional communication. Generally, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.

AUTHORS' CONCLUSIONS

Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. However, some trials were poorly reported. The potential benefits of intensive SLT over conventional SLT were confounded by a significantly higher dropout from intensive SLT. More participants also withdrew from social support than SLT interventions. There was insufficient evidence to draw any conclusion regarding the effectiveness of any one specific SLT approach over another.

Speech and language therapy for aphasia following stroke

BACKGROUND

Aphasia is an acquired language impairment following brain damage which 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.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched April 2009), MEDLINE (1966 to April 2009) and CINAHL (1982 to April 2009). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders, searched reference lists of relevant articles and contacted other researchers and authors.

SELECTION CRITERIA

Randomised controlled trials comparing SLT versus no SLT, SLT versus social support or stimulation, and one SLT intervention versus another SLT intervention. SLT refers to a formal speech and language therapy intervention that aims to improve language and communication abilities and in turn levels of communicative activity and participation. Social support and stimulation refers to an intervention which provides social support or communication stimulation but does not include targeted therapeutic interventions. Direct comparisons of different SLT interventions refers to SLT interventions that differ in terms of duration, intensity, frequency or method of intervention or in the theoretical basis for the SLT approach.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the quality of included trials. We sought missing data from study investigators if necessary.

MAIN RESULTS

We included 30 trials (41 paired comparisons) in the review: 14 subcomparisons (1064 participants) compared SLT with no SLT; six subcomparisons (279 participants) compared SLT with social support and stimulation; and 21 subcomparisons (732 participants) compared two approaches to SLT. In general, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.

AUTHORS' CONCLUSIONS

This review shows some indication of the effectiveness of SLT for people with aphasia following stroke. We also observed a consistency in the direction of results which favoured intensive SLT over conventional SLT, though significantly more people withdrew from intensive SLT than conventional SLT. SLT facilitated by a therapist-trained and supervised volunteer appears to be as effective as the provision of SLT by a professional. There was insufficient evidence to draw any conclusions in relation to the effectiveness of one SLT approach over another.

Interventions for treating depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy.

AUTHORS' CONCLUSIONS

A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Interventions for treating depression after stroke

BACKGROUND

Depressive and anxiety disorders following stroke are often undiagnosed or inadequately treated. This may reflect difficulties with the diagnosis of abnormal mood among older people with stroke-related disability, but may also reflect uncertainty about the effectiveness of such therapies in this setting.

OBJECTIVES

To determine whether pharmacological, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

The Cochrane Stroke Group Trials Register (last searched June 2003). The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents with placebo, or various forms of psychotherapy with standard care (or attention control), in patients with recent, clinically diagnosed, acute stroke, where treatment was explicitly intended of treat depression.

DATA COLLECTION AND ANALYSIS

Primary analyses focussed on the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects. We did not pool the data for summary scores. We performed meta-analysis for only some binary endpoints and data on adverse events.

MAIN RESULTS

Nine trials, with 780 participants, were included in the review. Data were available for seven trials of pharmaceutical agents, and two trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was no strong evidence of benefit of either pharmacotherapy or psychotherapy in terms of a complete remission of depression following stroke. There was evidence of a reduction (improvement) in scores on depression rating scales, and an increase in the proportion of participants with anxiety at the end of follow up.

REVIEWERS' CONCLUSIONS

This review found no evidence to support the routine use of pharmacotherapeutic or psychotherapeutic treatment for depression after stroke. More research is required before recommendations can be made about the most appropriate management of depression following stroke.

Interventions for preventing depression after stroke

BACKGROUND

Abnormal mood is an important consequence of stroke and may affect recovery and outcome. However, depression and anxiety are often not detected or inadequately treated. This may in part be due to doubts about whether anti-depressant treatments commenced early after the onset of stroke will prevent depression and improve outcome.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent the onset of depression, including depressive illness and abnormal mood, and improve physical and psychological outcomes, in patients with stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (June 2003). In addition we searched the following electronic databases: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1980 to September 2002), CINAHL (1982 to September 2002), PsychINFO (1967 to September 2002), Applied Science and Technology Plus (1986 to September 2002), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), General Science Plus (1994 to September 2002), Science Citation Index (1992 to September 2002), Social Sciences Citation Index (1991 to September 2002), and Sociofile (1974 to September 2002). Reference lists from relevant articles and textbooks were searched, and authors of known studies and pharmaceutical companies who manufacture psychotropic medications were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing different types of pharmaceutical agents (eg selective serotonin reuptake inhibitors) with placebo, or various forms of psychotherapy against standard care (or attention control), in patients with a recent clinical diagnosis of stroke, where the treatment was undertaken with the explicit intention of preventing depression.

DATA COLLECTION AND ANALYSIS

The primary analyses focussed on the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow-up. Secondary outcomes included depression or mood scores on standard scales, disability or physical function, death, recurrent stroke, and adverse effects.

MAIN RESULTS

Twelve trials involving 1245 participants were included in the review. Data were available for nine trials (11 comparisons) involving different pharmaceutical agents, and three trials of psychotherapy. The time from stroke onset to entry ranged from a few hours to six months, but most patients were recruited within one month of acute stroke. The duration of treatments ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or on other measures. A significant improvement in mood was evident for psychotherapy, but this treatment effect was small and from a single trial. There was no effect on diagnosed depression.

REVIEWERS' CONCLUSIONS

This review identified a small but significant effect of psychotherapy on improving mood, but no effect of either pharmacotherapy or psychotherapy on the prevention of depressive illness, disability, or other outcomes. More evidence is therefore required before any recommendations can be made about the routine use of such treatments to improve recovery after stroke.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Speech and language therapy for aphasia following stroke

BACKGROUND

Aphasia describes language impairment associated with a brain lesion.

OBJECTIVES

The objective of this review was to assess the effects of formal speech and language therapy and non-professional types of support from untrained providers for people with aphasia after stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched: March 1999), and reference lists of relevant articles to December 1998. We also contacted academic institutions and other researchers to identify further published and unpublished trials. We searched The International Journal of Disorders of Communication by hand (known by other names in the past), from 1969 to 1998. Date of most recent searches: January 1999.

SELECTION CRITERIA

Randomised controlled trials comparing: 1. Any type of formal speech and language therapy in any setting administered by trained speech and language therapists versus no treatment. 2. Any type of formal speech and language therapy in any setting administered by trained speech and language therapists versus any type of informal support for aphasia, given by speech and language therapists or volunteers, whether these were trained or untrained. 3. One type of speech and language therapy versus another type. Outcome measures included measures of any type of communication, other measures of functioning, numbers of drop-outs, and other non-clinical outcomes.

DATA COLLECTION AND ANALYSIS

The principal reviewer collected the data, and assessed the quality of the trials with independent data checking and methodological advice. If we could not perform a statistical combination of different studies, we sought missing data. Failing that we provided a description.

MAIN RESULTS

We considered sixty studies in detail, from which we identified twelve trials suitable for the review. Most of these trials were relatively old with poor or unassessable methodological quality. None of the trials was detailed enough for us to complete description and analysis. We could not determine whether formal speech and language therapy is more effective than informal support.

REVIEWER'S CONCLUSIONS

The main conclusion of this review is that speech and language therapy treatment for people with aphasia after a stroke has not been shown either to be clearly effective or clearly ineffective within a RCT. Decisions about the management of patients must therefore be based on other forms of evidence. Further research is required to find out if effectiveness of speech and language therapy for aphasic patients is effective. If researchers choose to do a trial, this must be large enough to have adequate statistical power, and be clearly reported.

Weightings of items on the Code-Müller Protocols: the effects of clinical experience of aphasia therapy

One hundred and twenty-two professionals engaged in aphasia therapy (graduates and undergraduates) ranked and weighted the relevance of the items of the Code-Müller Protocols (CMP) for assessing perceptions of psychosocial adjustment to aphasia using the multiattribute utility technique (MAUT). The degree of clinical experience with aphasia had a significant influence on participants' weightings of the items 'ability to follow interests and hobbies' and 'receiving speech therapy'.

Speech and language therapy: is it effective?

As part of a needs assessment of local speech and language therapy services, a review of the literature was carried out to examine the evidence for effectiveness of speech and language therapy. Purchasing authorities and general practice fundholders need to know whether what they are buying for their local population is effective, and whether the service is being provided in the most cost-effective way. This paper considers the published evidence and some of the limitations of the studies, and gives suggestions for purchasing speech and language therapy services based on current evidence. More evaluative work needs to be done to provide purchasers with the information necessary to decide which speech and language therapy services will result in real benefits for their population.