Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial
Apologies to Chris Code for not replying sooner, we have since covered some of his queries in replies to others.
1. Spontaneous recovery – The study was designed with two predictions in mind (a) the likely spontaneous recovery during the first few months of stroke and (b) the likely attention (placebo+) effect of receiving regular contact with a therapist or visitor. Randomising participants means that spontaneous recovery is likely to occur in both the therapy and the control group. Therefore we tested for between group differences at six months i.e. whether there was any added benefit of seeing a qualified speech and language therapist over and above spontaneous recovery and any general psychosocial support from regular contact. So spontaneous recovery is not a difficulty to be avoided in future trials and we encourage further research in the early phase of the stroke pathway.
2. We entirely agree with Code’s suggestion that our employed visitors provided social interaction much like a good aphasia therapist would. However this was without years of degree level training to qualify as a therapist (and on a much lower salary) so it is reasonable to expect greater benefit from seeing a qualified therapist who offers not just interaction but theoretically driven therapy too. We also agree that we selected part-time visitors with excellent (not just averagely good) social skills but feel that this is misunderstood. Our visitors were individuals recruited through job adverts in the local newspaper for a rather low paid (~£15,000 pro rata) and short term salary. It was not difficult to recruit such excellent people and this could easily be replicated by NHS services. However they were deliberately not trained in stroke and were not trained ‘conversation partners’ as this term has come to be understood in aphasia. Their ‘training’ and monitoring related more to research governance and might be far less in clinical practice.
3. It is not accurate to describe the intervention designed and delivered by the speech and language therapists as “generalized”. Instead therapy was individualised within an agreed approach.
4. Aphasia is not more complex than other impairments and plenty of good stroke rehabilitation trials have demonstrated effectiveness where that is present. Advances in service delivery could potentially be made if theoretical expertise in aphasia were coupled with methodological developments in the evaluation of complex interventions.
Competing interests:
Nothing additional to those stated in our original paper.
16 October 2012
Audrey Bowen
Psychologist
Anne Hesketh, Emma Patchick, Alys Young, Linda Davies, Andy Vail, Andrew F Long, Caroline Watkins, Mo Wilkinson, Gill Pearl, Matthew A Lambon Ralph, Pippa Tyrrell
Rapid Response:
Re: Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial
Apologies to Chris Code for not replying sooner, we have since covered some of his queries in replies to others.
1. Spontaneous recovery – The study was designed with two predictions in mind (a) the likely spontaneous recovery during the first few months of stroke and (b) the likely attention (placebo+) effect of receiving regular contact with a therapist or visitor. Randomising participants means that spontaneous recovery is likely to occur in both the therapy and the control group. Therefore we tested for between group differences at six months i.e. whether there was any added benefit of seeing a qualified speech and language therapist over and above spontaneous recovery and any general psychosocial support from regular contact. So spontaneous recovery is not a difficulty to be avoided in future trials and we encourage further research in the early phase of the stroke pathway.
2. We entirely agree with Code’s suggestion that our employed visitors provided social interaction much like a good aphasia therapist would. However this was without years of degree level training to qualify as a therapist (and on a much lower salary) so it is reasonable to expect greater benefit from seeing a qualified therapist who offers not just interaction but theoretically driven therapy too. We also agree that we selected part-time visitors with excellent (not just averagely good) social skills but feel that this is misunderstood. Our visitors were individuals recruited through job adverts in the local newspaper for a rather low paid (~£15,000 pro rata) and short term salary. It was not difficult to recruit such excellent people and this could easily be replicated by NHS services. However they were deliberately not trained in stroke and were not trained ‘conversation partners’ as this term has come to be understood in aphasia. Their ‘training’ and monitoring related more to research governance and might be far less in clinical practice.
3. It is not accurate to describe the intervention designed and delivered by the speech and language therapists as “generalized”. Instead therapy was individualised within an agreed approach.
4. Aphasia is not more complex than other impairments and plenty of good stroke rehabilitation trials have demonstrated effectiveness where that is present. Advances in service delivery could potentially be made if theoretical expertise in aphasia were coupled with methodological developments in the evaluation of complex interventions.
Competing interests: Nothing additional to those stated in our original paper.