Evidence-based approach to speech therapy introduced for stroke patients

Aug. 31, 2004 -- Because physicians and surgeons rely on clinical trials to help determine how to treat their patients, a multidisciplinary team of researchers and speech therapists at Washington University School of Medicine in St. Louis and its affiliate, the Rehabilitation Institute of St. Louis, has developed a speech rehabilitation program for stroke patients that applies the same evidence-based approach.

Speech problems such as the inability to formulate coherent sentences or to understand verbal statements are collectively known as aphasia. There are multiple types of aphasia: including problems with reading, writing, speaking or understanding speech. But there is no standard protocol to determine which type of treatment is best for which type of patient. Speech therapists generally rely on their own experience and intuition to determine a patient's treatment regimen.

"What's different about our program is that we recommend using only cutting-edge treatments that have scientific evidence behind them," says Robert P. Fucetola, Ph.D., assistant professor of neurology. "We're also quantifying and evaluating them on an ongoing basis to continually improve our understanding of whether a particular intervention makes a difference for our patients."

According to the National Aphasia Association, approximately 1 million Americans suffer from the condition, and the majority develops aphasia after a stroke.

Fucetola recently reported on the team's methods at the 34th Annual Clinical Aphasiology Conference in Park City, Utah. The team includes Maurizio Corbetta, M.D., associate professor of neurology, of radiology and of anatomy and neurobiology and head of stroke and brain injury rehabilitation at the School of Medicine and the Rehabilitation Institute; Karen Blank, speech therapist at the Rehabilitation Institute; and Fran Tucker, Ph.D., a consulting aphasiologist in private practice.

The team performed a comprehensive review of scientific literature on aphasia rehabilitation techniques. Based on the data, the group developed four decision trees, one for each of the main types of aphasia. Each uses simple questions to guide the therapist, indicates treatment choices for specific types of patients and includes information on how strongly supported each technique is by scientific data.

"Over the past few years there have been many new studies that looked at what techniques work for which patients and when the best time is to begin a given technique during the recovery process," Fucetola says. "We spent a couple years synthesizing all that information to ensure that patients in our clinic get only evidence-based treatments."

Patients at the Rehabilitation Institute of St. Louis who enter the speech therapy program — now called the Evidence-Based Aphasia Clinic — first undergo a series of behavioral, neuropsychological and cognitive tests, often including brain scans. The team uses these assessments to select the appropriate decision tree and determine the best treatment regimen.

Patients are evaluated periodically by a member of the rehabilitation team who is not involved in that individual's treatment and does not know which treatment is being used. The team meets weekly to discuss results from their own experiences with various protocols and to review newly published studies. Based on these sessions, treatment options are added to — or sometimes removed from — the decision trees.

Robert Fucetola

Many treatments used by Fucetola and colleagues are not the standard techniques used in rehabilitation programs elsewhere. For example, the team recently employed a new technique reported in the literature about one year ago. The approach is similar to constraint-induced movement therapy, which already has been shown to help stroke patients recover motor function. In that therapy, a patient is forced to use an affected limb, thereby improving and strengthening that limb's ability to function. For example, an oven mitt may be securely placed on a patient's strong arm during therapy to encourage use of the other, weakened arm.

Research published about a year ago indicated that a similar constraint-induced approach could improve recovery of speech. If, for example, a patient has trouble composing grammatically correct sentences, constraint-induced speech therapy would require him to do just that.

The technique is employed using a card game similar to "Go Fish": A group of patients, each suffering from different speech problems, convenes several times a week to play the game . Each patient is given specific instructions on how to ask for cards from the other players, tapping into each patient's specific verbal weakness.

"Normally, speech therapists teach patients to compensate for their problem, using gestures to communicate if they can't do so with speech," Fucetola explains. "In contrast, constraint-induced therapy slowly but persistently eases them into improving their specific speech impediment."

The team plans to publish the decision trees soon so that others can use them to individualize speech rehabilitation for stroke patients on a more scientific basis.

Fucetola R, Tucker FT, Blank K, Corbetta M. An evidence-based aphasia clinic: A work in progress. 34th Annual Clinical Aphasiology Conference, 2004.

The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked second in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.