A feasibility randomized controlled trial of ReaDySpeech for people with dysarthria after stroke

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Management of communication disability in the first 90 days after stroke: a scoping review

INTRODUCTION

People with communication disability after stroke need interventions to optimise healthcare communication and rehabilitation outcomes. Current evidence syntheses do not adequately inform the management of communication disability during the first 90 days post-stroke.

PURPOSE

To explore the scope of literature for the management of communication disability in the first 90 days after stroke.

MATERIALS AND METHODS

A scoping review was conducted using a systematic keyword search of six databases. A descriptive synthesis was generated using communication-related domains related to the biopsychosocial framework of the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

A total of 129 studies met eligibility criteria. Aphasia was the most frequently addressed communication disability after stroke (76/129 studies) with a paucity of evidence investigating other acquired neurogenic communication impairments. Management predominantly focused on communication-related: body functions and structures (62 studies) (e.g., linguistic-behavioural therapies), followed by environmental factors (39 studies) (e.g., communication partner training/support); activities and participation (15 studies) (e.g., augmentative and alternative communication); and personal factors (13 studies) (e.g., assessment of depression after aphasia).

CONCLUSION

A coordinated, integrated approach to developing and testing acute and subacute interventions for all communication disabilities across all communication-related domains is required.IMPLICATIONS FOR REHABILITATIONInterdisciplinary stroke clinicians need to manage communication disabilities in the first 90 days after stroke to optimise healthcare communication and rehabilitation outcomes.There is some evidence to guide clinicians in aphasia management but less in other disabilities of speech and cognitive functioning.Most interventions to inform clinical practice address communication-related body functions and structures (e.g., linguistic and speech therapies). Clinicians need to address all domains and more evidence is needed to address environmental factors (e.g., communication support); activities and participation (e.g., person-centred goal setting); and personal factors (e.g., psychological care).

Comparison of Tongue Acupuncture and Traditional Acupuncture in the Treatment of Poststroke Dysarthria: A Meta-Analysis and Tongue Acupuncture System Classification Evaluation

OBJECTIVE

To discuss whether tongue acupuncture is more effective than traditional acupuncture in the treatment of poststroke dysarthria and explore the advantage of tongue acupuncture treatment parameters.

METHODS

We evaluated the efficacy of tongue acupuncture compared with traditional acupuncture through a rigorous meta-analysis process. The included studies were from eight databases in English and Chinese. The Cochrane risk of bias assessment tool was used to evaluate the quality of studies. Stata15.1 software was used for meta-analysis and sensitivity analysis. Tongue acupuncture therapeutic parameters were classified and counted based on tongue acupoint location, acupuncture manipulation, and the number of manipulations. Subgroup analysis was used to compare the differences between various treatment parameters. Outcome The meta-analysis eventually included a total of 9 studies. Tongue acupuncture is superior to traditional acupuncture in clinical efficacy [OR = 3.62, 95%Cl (2.24, 5.85), P < 0.0001], FDA score [SMD = -1.99, 95%Cl (-3.77, -0.21), P=0.028], and NIHSS score [WMD = 0.86, 95%Cl (0.15, 1.57), P=0.017, I2 = 31.7%] in the treatment of poststroke dysarthria. According to the classified statistics of tongue acupuncture treatment parameters, there are three kinds of tongue acupuncture points in 9 studies: lingual surface, sublingual, and both lingual surface and sublingual acupoints. The operation methods include the oblique stabbing of the root of the tongue, twisting after stabbing, and acupoint pricking. The number of operation methods varies from 1 to 3.

CONCLUSION

Tongue acupuncture outperforms traditional acupuncture in terms of clinical efficacy, FDA score, and NIHSS score in the treatment of poststroke dysarthria. The curative effect of sublingual acupoints is better than that of lingual surface acupoints, the combined use of multiple manipulations is better than that of a single manipulation, and acupuncture manipulation has a cumulative effect. PROSPERO registration number: CRD42021285722.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

A Systematic Review of Adherence Strategies for Adult Populations in Speech-Language Pathology Treatment

PURPOSE

Speech-language pathologists (SLPs) often advise adult patients to complete at-home programs in order to improve outcomes. Despite this widespread practice, relatively little is known about treatment adherence. The purposes of this systematic review were to identify adherence strategies and adherence tracking methods used by adult populations that are commonly treated by SLPs (i.e., dysphagia, aphasia, traumatic brain injury, dysphonia, dysarthria), and to identify the efficacy of these strategies.

METHOD

The systematic review was conducted in accordance with A Measurement Tool to Assess Systematic Reviews guidelines. A comprehensive literature search was performed in three databases (CINAHL, PubMed, and Web of Science).

RESULTS

Of the 679 articles found, 18 were selected for analysis. Two thirds of the included articles received the second highest rating on the 5-point JAMA Quality Rating Scheme. Interventions designed to alter treatment adherence included (most to least frequent) computer programs, portable devices/phone apps, alarm reminders, instructional DVDs, check-ins from a clinician/volunteer, and wearable device. Adherence reporting methods included (most to least frequent) self-report diaries, computer program/app-aided collection, wearable device, and clinician/volunteer observation. Of the articles that reported practice frequency, 58% found that adherence strategies improved practice frequency as compared to control. Of the articles that reported treatment outcomes, 66% found that adherence strategies were associated with improved treatment outcomes as compared to control.

CONCLUSIONS

The paucity of publications reviewed suggests that treatment adherence is considerably understudied in speech-language pathology. A clearer understanding of how to improve the design of adherence strategies could yield highly valuable clinical outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19393793.

Speech rehabilitation in dysarthria after stroke: a systematic review of the studies

INTRODUCTION

Speech difficulties such as dysarthria or aphasia are frequently seen, in addition to motor impairments, in subjects after stroke.

EVIDENCE ACQUISITION

Literature searches with the keywords: "stroke" AND "dysarthria" AND "speech therapy" OR "language therapy" were conducted in PubMed, EMBASE, Cochrane Library and Web of Science to perform the systematic review about the several strategies used to treat dysarthria in subjects after stroke. The search was performed independently by two authors (CR and VM) from December 15th 2019 to January 15th 2020, using the PICOS criteria: participants were aging adults (>18 years old) affected by stroke; intervention was based on rehabilitation speech therapy; comparator was any comparator (all logopedic and speech rehabilitation tools); outcomes included clinical assessments, diagnostic scales and acoustic analysis of voice; and study design was RCTs, case series and case report, observational studies. The research identified a total of 94 articles for the first search and 56 for the second search. Sixty selected articles were analyzed by the reviewers. Twenty-five publications met the inclusion criteria and were included in the systematic review. Thirty-three articles were excluded for the following reasons: 12 involved individuals with aphasia or other speech problems different from dysarthria, 10 examined the clinical features of dysarthria, 3 treated on the impact of dysarthria on social participation following stroke, 8 did not include cases after stroke.

EVIDENCE SYNTHESIS

A systematic review was performed to identify the main used speech rehabilitation treatments for dysarthria after stroke. We defined the several techniques to better guide the physician to delineate a speech rehabilitation protocol adopting the better strategies described in the current literature.

CONCLUSIONS

This systematic review tried to provide to the reader a complete overview of the literature of all possible different speech treatments for dysarthria after stroke. A correct protocol could permit to improve the communication and the quality of life of these subjects.

Dysarthria and stroke. The effectiveness of speech rehabilitation. A systematic review and meta-analysis of the studies

INTRODUCTION

Speech difficulties, such as dysarthria or aphasia, in addition to motor impairments are frequently seen in post-stroke patients.

EVIDENCE ACQUISITION

Literature searches with the keywords: "stroke" and "dysarthria" and "diagnosis" and "stroke" and "dysarthria" and "assessment" were conducted using PubMed, EMBASE, Cochrane Library, and Web of Science databases to perform the systematic review about the methods used to measure the severity of dysarthria in subjects post-stroke. The search was performed by two authors from 15 January to 22 February 2020. The research identified a total of 402 articles for the search using the keywords "stroke" and "dysarthria," and "diagnosis" and 84 references for the search using the keywords "stroke" and "dysarthria" and "assessment." Sixty-nine selected articles were analyzed by the reviewers. Thirty-seven publications met the inclusion criteria and were included in the systematic review. Thirty-two articles were excluded for several reasons: 1) 12 involved individuals with aphasia or other speech problems different from dysarthria; 2) 12 examined different topics from our aim; and 3) eight did not include post-stroke cases.

EVIDENCE SYNTHESIS

The systematic review identified methods for measuring the severity of post-stroke dysarthria. The meta-analysis showed the acoustic parameters affected in dysarthria secondary to stroke and the differences in these parameters after speech therapy.

CONCLUSIONS

The alternating and sequential motion rate (AMR- Pə, AMR-Tə, AMR-Kə, and SMR-PəTəKə) and maximum phonation time were significantly improved after speech rehabilitation.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background

Therapy is key to effective stroke care, but many patients receive little.

Objectives

To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.

Design

Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.

Setting

Stroke services in England, Wales and Northern Ireland.

Participants

A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.

Results

Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.

Limitations

Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.

Conclusions

Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.