Dose effects in behavioural treatment of post-stroke aphasia: a systematic review and meta-analysis

Harvey, Sam; Carragher, Marcella; Dickey, Michael Walsh; Pierce, John; Rose, Miranda

doi:10.1080/09638288.2020.1843079

Cited by 43 publications

(16 citation statements)

References 66 publications

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“…The results demonstrated that, across all domains, each additional day of practice per week was associated with a significantly greater improvement over time, with the exception of 4 versus ≥5 days per week. The nonsignificant difference in performance outcome at the upper end of the practice frequency range raises the possibility of diminishing returns, a finding that has also been suggested in other recent work and may be explained by a ceiling effect for certain impairment-based therapies [30]. The existence of a lower threshold for improvement is similarly a source of debate in the limited available literature; for instance, a prior study found no significant differences in outcome for therapy delivered for 48 versus 24 total hours [33].…”

Section: Summary Of Findingssupporting

confidence: 70%

“…Dose articulation studies are a critical first step toward establishing optimal dosage recommendations for SLT interventions [28,29]. To date, only a handful of studies have directly compared different dosage amounts of the same intervention, and none have done so in the context of self-managed digital therapies [30][31][32][33][34][35][36].…”

Section: Introductionmentioning

confidence: 99%

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Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Cordella¹,

Munsell²,

Godlove³

et al. 2022

J Med Internet Res

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Background Although the efficacy of high-dose speech-language therapy (SLT) for individuals with poststroke aphasia has been established in the literature, there is a gap in translating these research findings to clinical practice. Therefore, patients continue to receive suboptimal amounts of SLT, with negative consequences for their functional communication recovery. Recent research has identified self-managed digital health technology as one way to close the dosage gap by enabling high-intensity therapy unrestricted by clinician availability or other practical constraints. However, there is limited empirical evidence available to rehabilitation professionals to guide dose prescriptions for self-managed SLT despite their increasing use in the COVID-19 era and likely beyond. Objective This study aims to leverage real-world mobile health data to investigate the effects of varied dosage frequency on performance outcomes for individuals with poststroke speech, language, and cognitive deficits following a 10-week period of self-managed treatment via a commercially available digital health platform. Methods Anonymized data from 2249 poststroke survivors who used the Constant Therapy app between late 2016 and 2019 were analyzed. The data included therapy tasks spanning 13 different language and cognitive skill domains. For each patient, the weekly therapy dosage was calculated based on the median number of days per week of app use over the 10-week therapy period, binned into groups of 1, 2, 3, 4, or ≥5 days per week. Linear mixed-effects models were run to examine change in performance over time as a function of dosage group, with post hoc comparisons of slopes to evaluate the performance gain associated with each additional day of practice. Results Across all skill domains, linear mixed-effects model results showed that performance improvement was significantly greater for patients who practiced 2 (β=.001; t15,355=2.37; P=.02), 3 (β=.003; t9738=5.21; P<.001), 4 (β=.005; t9289=7.82; P<.001), or ≥5 (β=.005; t6343=8.14; P<.001) days per week compared with those who only practiced for 1 day per week. Post hoc comparisons confirmed an incremental dosage effect accumulating with each day of practice (ie, 1 day vs 2 days, 2 days vs 3 days, and 3 days vs 4 days), apart from 4 days versus ≥5 days of practice per week. The result of greater improvement for higher versus lower dosage frequency groups was true not only across all domains but also within a majority of individual subdomains. Conclusions The findings from this study demonstrated that increased dosage frequency is associated with greater therapy gains over a 10-week treatment period of self-managed digital therapy. The use of real-world data maximizes the ecological validity of study results and makes the findings more generalizable to clinical settings. This study represents an important step toward the development of optimal dose recommendations for self-managed SLT.

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Section: Summary Of Findingssupporting

confidence: 70%

Section: Introductionmentioning

confidence: 99%

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Cordella¹,

Munsell²,

Godlove³

et al. 2022

J Med Internet Res

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“…A comprehensive review of this issue found insufficient evidence to recommend an optimal dosage that would result in maximum treatment outcome. 61 Although it seems highly plausible that more aphasia therapy is better in almost any case of aphasia, treatment dose as a pre-dictor of outcome remains under-studied. For a comprehensive review of this issue, readers are referred to Harvey et al 61…”

Section: Predicting the Outcome Of Behavioral Therapy Of Aphasiamentioning

confidence: 99%

Current Approaches to the Treatment of Post-Stroke Aphasia

Fridriksson

Hillis

2021

J Stroke

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Aphasia, impairment of language after stroke or other neurological insult, is a common and often devastating condition that affects nearly every social activity and interaction. Behavioral speech and language therapy is the mainstay of treatment, although other interventions have been introduced to augment the effects of the behavioral therapy. In this narrative review, we discuss advances in aphasia therapy in the last 5 years and focus primarily on properly powered, randomized, controlled trials of both behavioral therapies and interventions to augment therapy for post-stroke aphasia. These trials include evaluation of behavioral therapies and computer-delivered language therapies. We also discuss outcome prediction trials as well as interventional trials that have employed noninvasive brain stimulation, or medications to augment language therapy. Supported by evidence from Phase III trials and large meta-analyses, it is now generally accepted that aphasia therapy can improve language processing for many patients. Not all patients respond similarly to aphasia therapy with the most severe patients being the least likely responders. Nevertheless, it is imperative that all patients, regardless of severity, receive aphasia management focused on direct therapy of language deficits, counseling, or both. Emerging evidence from Phase II trials suggests transcranial brain stimulation is a promising method to boost aphasia therapy outcomes.

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“…As hours of therapy alone has very little predictive power, the results suggest that the benefit of increased therapy depends on lesion location. This may explain why detecting therapy dose effects has been so challenging [21]. Notably, we could not predict training effort, as indexed by hours of therapy undertaken at the individual level, from any of the other data considered here.…”

Section: Discussionmentioning

confidence: 89%

Lesion site and therapy time predict responses to a therapy for anomia after stroke: a prognostic model development study

Hope

Nardo

Holland

et al. 2021

Preprint

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BACKGROUND: Stroke is a leading cause of disability, and language impairments (aphasia) after stroke are both common and particularly feared. Most stroke survivors with aphasia exhibit anomia (difficulties with naming common objects), but while many therapeutic interventions for anomia have been proposed, treatment effects are typically much larger in some patients than others. Here, we asked whether that variation might be more systematic, and even predictable, than previously thought. METHODS: 18 patients, each at least 6 months after left hemisphere stroke, engaged in a computerised treatment for their anomia over a 6 week period. Using only: (a) the patients' initial accuracy when naming (to-be) trained items; (b) the hours of therapy that they devoted to the therapy; and (c) whole-brain lesion location data, derived from structural MRI; we developed Partial Least Squares regression models to predict the patients' improvements on treated items, and tested them in cross-validation. RESULTS: Somewhat surprisingly, the best model included only lesion location data and the hours of therapy undertaken. In cross-validation, this model significantly out-performed the null model, in which the prediction for each patient was simply the mean treatment effect of the group. This model also made promisingly accurate predictions in absolute terms: the correlation between empirical and predicted treatment response was 0.62 (95%CI: 0.27, 0.95). DISCUSSION: Our results indicate that individuals' variation in response to anomia treatment are, at least somewhat, systematic and predictable, from the interaction between where and how much lesion damage they have suffered, and the time they devoted to the therapy.

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Dose effects in behavioural treatment of post-stroke aphasia: a systematic review and meta-analysis

Cited by 43 publications

References 66 publications

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

Current Approaches to the Treatment of Post-Stroke Aphasia

Lesion site and therapy time predict responses to a therapy for anomia after stroke: a prognostic model development study

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