Combining computer-based speech and language therapy with usual NHS care can help some people improve their communication following a stroke.
Published: 20 October 2022
Communication loss after stroke reduces quality of life
Improvements in emergency treatment and care mean that fewer people in the UK now die from strokes. There are 1.2 million stroke survivors in the UK and two thirds will have left hospital with a disability caused by damage to different parts of their brain.
Around a third of stroke survivors develop aphasia – a communication disorder that affects their ability to understand, talk, read and write. As many as one fifth struggle with long-term aphasia, with up to 350,000 people in the UK living with aphasia and its damaging effects on their confidence, relationships and work.
Speech and language therapy to help people regain and improve their language ability is usually offered by the NHS in the early weeks after a stroke. Although people’s communication can improve for several years after a stroke, pressure on NHS resources means that therapy is rarely available beyond 3 months. This is particularly the case for those with mild difficulties finding words, meaning patients’ recovery and quality of life can be limited.
Dr Rebecca Palmer, Reader in Communication and Stroke Rehabilitation at the University of Sheffield, explained how ongoing therapy was key to people’s recovery, saying: “People suffering from communication difficulties after stroke may have the potential to improve their communication little by little over time with continued practice.”
“We wanted to give people the opportunity to practise more without placing more demands on limited speech and language therapists’ time, so we turned to technology to help us.”
Beginning with their NIHR Research for Patient Benefit Programme-funded pilot study, CACTUS, Dr Palmer and her team at the University of Sheffield investigated whether a specialist computer therapy programme, StepByStep, could support improvement in language for people with aphasia. Dr Palmer said: “We found that people who practised finding their words at home using the computer programme were able to name more words after five months than those who received the usual NHS care of three months’ face-to-face therapy.”
Their results, alongside improvements to patients’ quality of life from regaining their communication skills, suggested that computer therapy could be an effective way forward. The next step was to provide firm evidence about whether computer therapy could be effective and cost-effective in a large, randomised controlled trial.
Supported by a £1.5 million award from the NIHR Health Technology Assessment Programme, the team at the University of Sheffield, in collaboration with the University of Manchester and Glasgow Caledonian University, began recruiting patients to their Big CACTUS trial.
Independent computer therapy improves language skills
In the first multicentre randomised controlled trial of its kind, the Big CACTUS trial recruited 278 patients with post-stroke aphasia from 20 NHS speech and language therapy departments across the UK. All patients had experienced a stroke between four months and 36 years before the trial and were assessed as having mild (44%), moderate (30%) or severe (26%) word finding difficulties.
Dr Palmer said: “We wanted to know whether using computers for therapy was effective in addition to available face-to-face speech and language therapy offered by the NHS.” Patients were therefore randomly assigned to receive six months of available speech and language therapy on its own, or available therapy, with either the addition of 20–30 minutes daily computer therapy or the addition of puzzle book activities and phone calls from a researcher.
The computer therapy group practised words tailored to them on a computer at home, while the activities in the puzzle book group mimicked the practise and attention received by those receiving computer therapy.
Published in The Lancet Neurology, the trial’s results showed that computer therapy significantly improved people’s ability to recall words they had chosen to learn. Importantly, patients could still say those words six months after the computer therapy had finished.
People in the computer therapy group showed a 16% improvement in their word finding skills compared with those receiving available speech and language therapy alone, and a 14% improvement compared with the puzzle and phone call group. These improvements were not related to the length of time since their stroke.
Although using the words in conversation, general conversation ability or self-evaluated quality of life did not notably increase, carers rated their relatives’ everyday communication abilities as 5% higher following computer therapy. The impact of computer therapy for one patient was summed up by her husband, who commented:
“My wife can have a polite conversation with someone now, and that’s good to see. I believe it all basically started with that programme [the Big CACTUS trial].”
Offering patients hope for further recovery
The Big CACTUS project provided clear evidence that self-managed computer therapy can be successfully incorporated into speech and language therapy services. This approach offered people with aphasia the opportunity to frequently and independently practice words they wanted to be able to say again. Their enthusiasm was noted by Dr Palmer, who commented: “The fact that 61% patients continued to use the computer therapy after the end of the trial showed that people with aphasia wanted to continue learning words and could do this independently”.
On average, computer therapy cost £733 per person – around half the cost of face-to-face therapy. The team’s cost analysis, published in the journal Health Technology Assessment, showed that this was unlikely to offer good value for everyone with aphasia. However, it was likely to be cost-effective for those with mild to moderate aphasia as these groups made slightly greater improvements during the trial.
The outcomes of the Big CACTUS trial are now impacting on policy and practice, and have influenced international recommendations in the World Federation for NeuroRehabilitation’s 2021 Clinical Pathways in Stroke Rehabilitation, which are used by clinicians, nurses and therapists around the world. The results have also been shared with NICE for its 2023 update of the current NICE guideline on stroke rehabilitation.
The team also held a knowledge exchange event at the University of Sheffield attended by health professionals, commissioners, NHS trust directors, patients and carers, and software developers. Influenced by this, the commercial StepByStep software for people with aphasia was improved in line with the trial’s findings. In addition, a new commercial app, CueSpeak, incorporated the most important 100 words identified by people with aphasia in the trial (published in PLOS ONE). The app has been downloaded 27,500 times worldwide, demonstrating the trial’s wide-reaching impact for people with aphasia.
Following the positive trial outcomes, participating NHS Trusts increased their investment in technology to offer computer therapy to new patients. The impact of this was particularly apparent during the Covid-19 pandemic, during which Trusts could deliver effective computer therapy remotely and help patients continue their recovery at home.
Trusts’ participation also markedly raised their speech and language therapy services’ profile, creating new opportunities for speech and language therapists to train and support other staff in the use of computer therapy. It also increased participation in research and influenced the teams’ focus on evidence-based practice.
Involving patients and the public (PPI) in the planning and design is at the centre of NIHR research and was a key factor in the success of both the CACTUS and Big CACTUS trials. Their close involvement ensured that the interventions and trial materials were manageable and appropriate for all participants.
After the trial, the PPI group helped to prepare and disseminate practical and accessible resources, including results booklets and a video, that both patients with aphasia and NHS practitioners could benefit from.
“We hope that the successful Big CACTUS computer therapy approach gives people living with aphasia hope for further recovery as part of a speech and language therapy programme alongside other interventions that focus on using new language in conversation, participating in everyday activities and improved wellbeing.” Dr Rebecca Palmer
The study was funded by NIHR’s Health Technology Assessment (HTA) Programme.
The pilot study, CACTUS, was funded by NIHR’s Research for Patient Benefit (RfPB) Programme. This study was also supported by the Stroke and Telehealth themes of the former South Yorkshire Collaboration for Leadership in Applied Health Research and Care (CLAHRC).
More information about the studies is available on the NIHR’s Funding & Awards website.