Behind the therapy door: what is “usual care” aphasia therapy in acute stroke management?

Abstract

Background: Usual care is the term used to describe everyday practice in the management of a client within a profession. The knowledge of the tasks used in therapy and key therapeutic processes used within these treatments, provides critical information about if and how the therapy works. The Very Early Rehabilitation in SpEech Randomised Controlled Trial (VERSE RCT) had three arms with therapists within the intensive Usual Care-Plus arm (UC-Plus) providing daily direct aphasia therapy at their discretion for 20 sessions. Aims: To describe usual care aphasia treatment provided in the Usual Care-Plus arm of VERSE RCT. Methods and Procedures: One in four intensive Usual Care-Plus treatment sessions were video-recorded (N = 187) within the main trial. Twenty-five of these (13%) were transcribed, coded, and analysed for therapeutic inputs to describe usual care aphasia therapy using the Template for Intervention Description and Replication (TIDieR) checklist as an overriding framework. Outcomes and Results: Therapy predominantly took place in an inpatient setting (52%) with an average session duration of 51 minutes (SD 7.8). Across the sessions, 96 different tasks were used and 57% of these focused on verbal expression at the single word level. Visual materials were most frequently used compared to the use of technology during sessions. Therapists (n = 16) did the majority of the talking during sessions and most frequently provided models as cues or problemsolving accuracy feedback. Models (55%), sentence completion (51%), and orthographic cues (44%) were the most successful at eliciting the target response. Conclusions: Considerable variability in task selection was seen in the sample which may be a hallmark of usual care. Therapists may have a preference for single word tasks and appear to produce the majority of verbal utterances during sessions, potentially creating an unequal communication environment. This study provided a comprehensive description from the Usual Care-Plus data of the VERSE RCT and may establish a baseline of therapy type for future research.

A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study

“…7 Our current findings were unexpected, based on our pilot studies 5,18 which showed significant benefit of early, intensive aphasia treatment. In addition, we found a considerable increase in the amount of aphasia therapy provided as usual care, but not in the type of therapy provided, 37 compared with the results of our pilot trial. 5 Our Phase I trial 5 was conducted over 10 years ago, and at this time, among the 15% of participants who received aphasia therapy, only 14 min was provided in a single session over three weeks.…”

Advancing Stroke Recovery Through Improved Articulation of Nonpharmacological Intervention Dose

“…• Duration of practice reflected by time spent in a therapy space [20][21][22] or time on task, 5,23 for example, minutes/hours; • Schedule of therapy, for example, frequency of sessions, days/week [24][25][26] ; • Task difficulty, for example, challenge point 27 ; or • Physical intensity, for example, Borg rating scale, 28 heart rate reserve, 29 metabolic equivalent of task, 29 or repetitions. 5 The breadth and diversity of unidimensional approaches to articulate dose suggest there is a global lack of agreement.…”

Treatment fidelity monitoring, reporting and findings in a complex aphasia intervention trial: a substudy of the Very Early Rehabilitation in SpEech (VERSE) trial

“…Further, the treatment fidelity reported here was completed at the macrostructure level. Previously published work [22,23] presents finer grained, utterance level analyses and adds nuanced therapeutic information to the efficacy picture. Finally, the receipt of treatment and enactment of treatment skills areas of Bellg et al [5] were not measured in this study and so cannot be commented on.…”