Royal College of Speech and Language Therapists



Self-managed computer therapy for people with aphasia post stroke(Dr Rebecca Palmer, University of Sheffield and Sheffield Teaching Hospitals)An example towards the NHS Five year forward view covering:Self-management of conditionsSupporting different working practicesThere is evidence to suggest targeted and intensive SLT treatments can promote further improvement through neuroplasticity in the longer term after a stroke, alleviating some of the distressing and costly consequences of persisting aphasia.Continuing to provide face to face therapy intensively over a long period of time is costly and unsustainable. Computerised therapy developed for the treatment of aphasia has been reported to be useful in the provision of targeted language therapy and provides opportunities for independent home practice to maximise intensity, improving outcomes for reading, spelling and expressive language.State of the evidence/researchOur National Institute for Health Research (NIHR)funded study piloted a randomised controlled trial of the cost effectiveness of self-managed computer treatment for people with aphasia at least six months post stroke. Thirty four participants were randomised to computer treatment or usual care for five months.The intervention tested in our pilot study involved trained volunteers to provide technical support and encouragement to promote compliance with sustained independent practice. On average, four hours and 50 minutes of SLT intervention and four hours and eight minutes of volunteer support enabled a further 25 hours of self-managed practice of computerised language exercises per patient. This efficient approach to treatment for people with persistent aphasia was feasible to deliver and an acceptable alternative to face to face treatment for people with aphasia. In addition to significant improvements in word finding ability (p=0.014), interview data showed that participants felt better able to have a conversation and had greater confidence following the treatment, suggesting that this intervention could reduce the burden of persistent aphasia. The incremental cost effectiveness ratio (ICER) was only ?3,285 per additional QALY (quality adjusted life year) gained, suggesting that the intervention is likely to be cost effective based upon an ICER threshold of ?20,000 per additional QALY gained [11] As a result of this study, such an approach has been highlighted in the recently published NICE guidelines for stroke rehabilitation. A further multicentre trial with 285 participants, ‘Big CACTUS’, is being carried out at the University of Sheffield to confirm this, funded by the NIHR Health Technology Programme and Tavistock Trust for Aphasia. SLT departments at 20 NHS trusts are involved in this trial and, in addition to data on the clinical and cost effectiveness of the self-computer intervention, we will collect qualitative information from all of the SLTs involved about how the intervention is being implemented at each trial site (barriers, solutions and benefits to service delivery).Implementation of self-managed computer therapyFollowing success of the pilot study, Sheffield Teaching Hospitals implemented and evaluated self-managed computerised aphasia therapy to deliver additional hours of intensive therapy as follows:-429260134620The service evaluated: long term self-directed computerised SLTfor people with aphasia post stroke within Sheffield Teaching HospitalsCLAHRC South Yorkshire funded STH to provide an option for intensive self-managed aphasia therapy using a range of specially designed computer software packages to treat reading, writing, understanding and speaking/word finding. REACT 2 and Step-by-step software packages were chosen and suitable apps for iPad and android devices were identified according to individual requirements. A speech and language therapist was available for two sessions a week to assess the suitability of the patient for self-management and set up the appropriate computer software and exercises tailored to their specific needs/therapy goals. The software was provided for three months in the first instance, either installed on the patient’s own computer or loaned to them on a lap top. The patients were advised to practice for 20-30 minutes, four or five days a week. The computerised therapy exercises provide feedback to the patient on how well they were doing, and provided exercises of increasing levels of difficulty as progress is achieved.The speech and language therapist monitored progress and provided motivation to practice through telephone calls every 2-3 weeks, or by e-mail. The software packages used have tele-monitoring functions built in through which the therapist could monitor the activity of the patients remotely and provide new advice/exercises without requiring additional patient visits.The speech and language therapist recruited, trained and supported volunteers who visited the patients to provide support with the computer software, motivation to exercise, and practice using the newly acquired language in everyday contexts. At the end of three months, all patients were reviewed by the speech and language therapist to see if goals had been achieved and to see whether sufficient intensive therapy has been received or whether there is further potential and desire for improvement. If the latter was the case, software was purchased by the patient for permanent long term use. Alternatively, where support was required for purchasing software, the therapist assisted the patient in investigating charitable funding of the software. 00The service evaluated: long term self-directed computerised SLTfor people with aphasia post stroke within Sheffield Teaching HospitalsCLAHRC South Yorkshire funded STH to provide an option for intensive self-managed aphasia therapy using a range of specially designed computer software packages to treat reading, writing, understanding and speaking/word finding. REACT 2 and Step-by-step software packages were chosen and suitable apps for iPad and android devices were identified according to individual requirements. A speech and language therapist was available for two sessions a week to assess the suitability of the patient for self-management and set up the appropriate computer software and exercises tailored to their specific needs/therapy goals. The software was provided for three months in the first instance, either installed on the patient’s own computer or loaned to them on a lap top. The patients were advised to practice for 20-30 minutes, four or five days a week. The computerised therapy exercises provide feedback to the patient on how well they were doing, and provided exercises of increasing levels of difficulty as progress is achieved.The speech and language therapist monitored progress and provided motivation to practice through telephone calls every 2-3 weeks, or by e-mail. The software packages used have tele-monitoring functions built in through which the therapist could monitor the activity of the patients remotely and provide new advice/exercises without requiring additional patient visits.The speech and language therapist recruited, trained and supported volunteers who visited the patients to provide support with the computer software, motivation to exercise, and practice using the newly acquired language in everyday contexts. At the end of three months, all patients were reviewed by the speech and language therapist to see if goals had been achieved and to see whether sufficient intensive therapy has been received or whether there is further potential and desire for improvement. If the latter was the case, software was purchased by the patient for permanent long term use. Alternatively, where support was required for purchasing software, the therapist assisted the patient in investigating charitable funding of the software. Therapy outcome measures were taken before and after treatment for the first 19 patients who received intervention this way. Figure 1 shows how each patient improved in at least one domain following treatment.Figure 1 Comparison of baseline and outcome TOMS - impairment, activity, participation and wellbeingFigure 2 shows that a small amount of time from the therapist in setting up software and supporting/monitoring progress remotely (74 hours in total), enabled significantly more therapy hours to be self-administered through independent practice (610 hours in total).Figure 2. Therapist input time and self-directed therapy timeCase examples-30226016192500Patient ZF is a 78 year old lady who suffered a stroke in July 2012. She acquired aphasia from her stroke and was treated for this by speech and language therapy services on the stroke unit and then in the Community Intermediate Care team. At the end of intermediate care (4 months after her stroke), ZF was still not able to read sufficiently well to read crochet patterns or read the bible, reducing her quality of life. She was referred for further intensive treatment of her reading disorder in November 2012 via self-managed computerised aphasia therapy. We provided ZF with REACT 2 software on a loaned lap top computer and helped her to learn how to use the most appropriate reading exercises. ZF had never used a computer before.It took 3 ? hours of speech and language therapist time to assess ZF’s needs, install and set up the computer software, show her how to use this and review how she was getting on every 2-3 weeks by telephone. In the 3 months that ZF had the computer software, she carried out 29 hours of independent therapy practice. This resulted in improvements in her reading ability with her comprehension of written sentences improving from 50% to 75% and her own perception of her general communication ability improving from 60% to 74%. ZF can now read sufficiently well to follow crochet patterns. She wished to continue to use the computer beyond the initial 3 months. The family purchased a lap top for her use and we applied for charitable funding to purchase the software for long term use. ZF continues to carry out independent therapy practice whenever she wishes.When asked what she thought about the value of continuing to provide such a service she reported ‘I think it would be very good’. -42926013716000Patient LM is a 64 year old man who had a severe stroke resulting in severe physical and language difficulties. LM and his wife were very motivated to try to regain some language ability therefore following intensive face to face therapy from the community intermediate care team LM was referred for self-managed therapy with a computer, the only option for continuing intensive impairment based therapy.On initial assessment, although clearly motivated with a positive attitude, LM was unable to understand any spoken language. He was unable to read or write/spell. In addition to aphasia, LM also has severe apraxia of speech. Through much work in CICS he had acquired the ability to say ‘ah’, ‘ee’ and ‘oo’ although he was not always able to imitate the correct sound. We used Step-by-step? software and set up exercises to address spoken and written understanding of key words, spelling of key words and practise producing a wider range of speech sounds to move towards use of speech. Assessment, set up and monitoring over a three month period required 5 hours and 40 minutes of speech and language therapist time. Over 120 days, LM practiced independently for 125 hours with 7 hours of support from an STH volunteer.Following this self-managed intensive therapy, LM can now understand single words in a sentence, read single words, spell words (this may help him to use his iPad to communicate his needs) and can now produce a wider range of speech sounds. LM and his wife have found this mode of intensive therapy so useful that they have purchased the software for long term use, giving him the opportunity to continue to improve his language ability, increasing his ability to actively participate in life.-392430-22923500Patient JM is a 36 year old stroke survivor who acquired mild aphasia in November 2012. He was seen for speech and language therapy in the community intermediate care team. As he was independent, motivated and familiar with computer technology, the availability of computerised therapy enabled him to be discharged from CICS a month earlier than normal. He was referred in January 2013.As a university lecturer, JM’s goal was to be able to remember his work related vocabulary so that he could return to his role. Step-by-step? software was installed on a lap top for his use. JM came up with a list of words that were important for him to be able to say. As many of these were not in common use, the computer software did not contain these words in its library, therefore the speech and language therapist drew and described the words, photographed them and recorded the first sound of each word to act as a cue. Assessment and set up took 4 hours and 50 minutes.JM was able retrieve the vocabulary he required for work after using the software for 1 month. He has now returned to work as a university lecturer and gave an oral presentation of his work at a conference in May 2013 for the first time since his stroke. “It’s definitely helpful” “I think the software is really useful for the recovery stage of the stroke “It gives you time on your own at the pace that you require”-45720016446500Seven years after his stroke, TS enjoyed going out for meals but was unable to read the menus very well. His wife described how he always ordered chicken as that was likely to be an option. The SLT visited him to assess his reading ability and to set up therapy exercises on his on . The therapist reviewed his progress with the exercises remotely and adjusted them accordingly. Assessment and monitoring took 2-3 hours in total.TS carried out 28 self-managed therapy sessions over a 4 month period. His progress was displayed graphically within the REACT2 programme and is shown for understanding of written paragraphs below: TS now orders from the full range of options on a restaurant menu! The work was recognised by the RCSLT in 2014 with the Sternberg award for innovation in clinical practice.Research papers from our work that describe different aspects of this intervention in greater detail and which forms part of the evidence base for this approach (available from Rebecca if of interest!):Palmer, R. (2015) Innovations in aphasia treatment after stroke: technology to the rescue. British Journal of Neuroscience Nursing, 11 (suppl 2) 38-42Palmer, R., Cooper, C., Enderby, P., Brady, M., Julious, S., Bowen, A., Latimer, N. (2015). Clinical and cost effectiveness of computer treatment for aphasia post stroke (Big CACTUS): study protocol for a randomised controlled trial. Trials, 16(18) doi:10.1186/s13063-014-0527-7Latimer, N. R., Dixon, S., & Palmer, R. (2013). Cost-utility of self-managed computer therapy for people with aphasia. Int J Technol Assess Health Care, 29(4), 402-409. Doi:10.1017/S0266462313000421Palmer, R., Enderby, P., & Paterson, G. (2013). Using computers to enable self-management of aphasia therapy exercises for word finding: The patient and carer perspective. International Journal of Language and Communication Disorders, 48(5), 508-521. Doi:10.1111/1460-6984.12024Palmer, R., Enderby, P., Cooper, C., Latimer, N., Julious, S., Paterson, G., . . . Hughes, H. (2012). Computer therapy compared with usual care for people with long-standing aphasia poststroke: a pilot randomized controlled trial. Stroke, 43(7), 1904-1911. Doi:10.1161/STROKEAHA.112.650671Palmer, R & Mortley J. From Idealism to Realism, step by step. Speech & Language Therapy in Practice, Winter 2011, pp29-32This is a summary of a large package of work in this area. For further details or clarification please contact Rebecca on r.l.palmer@sheffield.ac.uk, 0114 2220863 ................
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