Aphasia

Evidence Reviewed as of before: 27-11-2018
Author(s)*: Tatiana Ogourtsova, PhD OT; Laura Chartrand; Amy Henderson PhD student; Sandra Bélisle-L’Anglais; Julie-France Hénault; Lyna Kaing; Caroline Lévesque; Sia Ching Tran; Véronique Vaillant; Adam Kagan BSc; Annabel McDermott BOccThy
Expert Reviewer: Elizabeth Rochon
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Aphasia is a language impairment that typically results from damage to the left hemisphere of the brain and consequently, is a common impairment after stroke. The resulting language dysfunctions are roughly classified as expressive (e.g. Broca’s aphasia) or receptive (e.g. Wernicke’s aphasia).

An individual with Broca’s aphasia has a partial or total inability to speak or produce spontaneous speech. They often have no difficulty understanding others, however, thoughts and intentions are difficult to express and may be non-fluent in nature. This form of aphasia can also affect written communication.

An individual with Wernicke’s aphasia has a partial or total inability to understand spoken and sometimes written language. Expression of language may be fluent in nature, but can be difficult for the listener to understand.

The symptoms of global aphasia are those of severe Broca’s aphasia and Wernicke’s aphasia combined. There is an almost total reduction of all aspects of spoken and written language, in expression as well as comprehension.

This module contains 34 studies, where 21 of them are high quality randomized clinical trials (RCTs), 11 are fair quality RCTs, and 2 are non-RCTs. The majority of interventions (18 studies) were studied among patients with chronic stroke (i.e. 6 months or more post-stroke).

Overall, we identified different interventions for post-stroke aphasia and those include: constraint-induced aphasia therapy; speech language therapy-unspecified, task-oriented aphasia therapy; semantic/phonological training, action-embedded therapy, intentional gestures and visual gestural cueing, supported communication, technology-assisted training (computer and devices), behavioral aphasia therapy, cognitive linguistic therapy, and narrative aphasia intervention.

Patient/Family Information

Authors: Tatiana Ogourtsova, PhD OT; Maxim Ben-Yakov, BSc PT; Nicol Korner-Bitensky, PhD OT

Contributors: Jennifer Sweeney, M.S., CCC-SLP, S-LP (C) Founder, BC Aphasia Centre; Aura Kagan PhD – Aphasia Institute

What is aphasia?

Aphasia is a problem of language and communication that makes it difficult to understand or produce speech. It may also affect reading and writing ability. Aphasia affects about 30% of people who have had a stroke.

Why do people get aphasia after a stroke?

Our brain has two main areas responsible for language. One is for understanding language through reading or listening. The other is for making language by writing or speaking. The type and severity of aphasia depends on the area of the brain that was damaged, and the amount of damage to the brain.

Are there different types of aphasia?

There are two types of aphasia:

  1. Receptive aphasia is when a person has difficulty understanding what he/she hears or reads.
  2. Expressive aphasia is when a person has difficulty expressing him/herself by writing or talking.

How can I recognize aphasia?

Some people have mild aphasia after a stroke and have difficulty expressing themselves. For example, they may have difficulty finding a word to describe an object. They may say the beginning of a sentence, such as:

“I would like to have a…”, and then pause, as though they are trying to think of the right word.

For instance, instead of asking:

“What do you want to eat?”

you can ask them:

“Do you want a banana?”

Some people with aphasia are not able to speak, but they are able to write down what they want to say. Others may not be able to write or speak after the stroke.

Some people with aphasia no longer understand what you are saying to them. They may understand when you speak in one language (for example, the first language they learned) but not in another language that they also knew before the stroke.

Some people with aphasia may be unable to read after the stroke. This often comes as a shock to the person when they pick up a magazine or newspaper and the letters and words on the page have no meaning to them.

To better understand how someone with aphasia is feeling, think about being alone in a foreign country where you do not understand the language. You cannot make your needs understood and when people speak to you, you don’t understand them. This can be very frustrating and isolating.

It is important to remember that someone with aphasia can retain many of the cognitive and social skills he/she had before the stroke. However, these skills may be hidden or masked by the language difficulties. Individuals with aphasia are often incorrectly treated as though they are less capable. This can affect their social life and participation in community activities, which in turn can impact on their self-esteem and quality of life.

Who diagnoses and treats aphasia?

Speech-language pathologists (SLP’s), also known as speech therapists, are trained to diagnose the different types of aphasia and treat individuals with aphasia.

Other members of the stroke team, including nurses, psychologists or neuro-psychologists, occupational therapists, social workers, doctors/neurologists, and physical therapists also understand and can help with the difficulties caused by aphasia. They will try to communicate with the person who has aphasia using strategies that are known to make communication easier.

The SLP will also explain to the stroke team the specific problems that the person with aphasia is having, and will suggest strategies to make communication easier.

Does Speech Language Therapy (SLT) work?

Yes, SLT works! A recent high-quality study found that SLT can improve different skills related to language and communication in individuals in the chronic phase of stroke recovery (more than 6 months after stroke).

Are there different types of SLT?

Numerous SLT approaches exist for aphasia. Your SLP will help choose a suitable program according to your needs. These might include:

  • Constraint-induced aphasia therapy: you practice having a conversation with your therapist or peers mostly without using gestures or other non-verbal communication (e.g. nodding your head).
  • Task-oriented aphasia therapy: you will train to follow spoken commands that are important to your everyday activities.
  • Semantic treatment: your therapist will ask you questions about words that are difficult for you to remember, and you will answer them. For example, if you have difficulty remembering the word ‘television’, the therapist will ask you questions such as: ‘where is the object located?’ [‘living room’]; or ‘what is it used for? [‘to watch movies’].
  • Action-embedded therapy: you perform actions to match a verbal request, the name of a word or something you visualise in your mind.
  • Intentional gestures: you move your left hand to do a task (e.g. reaching for a box, pressing a button), while naming different objects shown on pictures.
  • Supported communication: you join in group discussions or talk with a trained conversation partner using both verbal and non-verbal communication (i.e. words, gestures, writing notes, miming, role play, etc.).
  • Technology-assisted training: you use computer programs or other technological devices in your treatment sessions.
  • Behavioral aphasia therapy: your therapist will provide you with education, activities and tasks to improve your mood.
  • Cognitive-linguistic therapy: your therapist will work with you to practice saying words and sentences, based on logic/decision-making and organization of sounds in words.
  • Narrative aphasia intervention: you practice saying words and sentences while discussing a range of everyday topics (for example: shopping for an item).
  • Very early intervention: you engage in various aphasia therapies as early as possible after having a stroke and when medically stable.

You might have also heard about recent high-tech treatments. For example, computer programs for aphasia can be very helpful for some people after stroke. These computer programs include microphones and recording devices that allow people with aphasia to practice talking. The person can hear him/herself speak and can correct their mistakes. Computer programs can also help people re-learn to read after a stroke. Computer programs allow you to practice in your own home, in your own time. You can use computer programs in addition to speech language pathology to practice techniques and special skills that your SLP has taught you.

Your SLP may choose one or a combination of these different therapies when working with you, based on your individual needs.

What therapies work for aphasia?

Research has tested the effect of aphasia therapies at different stages of stroke recovery. High and fair quality research studies show that the following interventions are useful in improving language and/or communication skills:

In the acute stage of stroke recovery
(up to 1 month after stroke):

  • constraint-induced aphasia therapy
  • very early intervention

In the subacute stage of stroke recovery
(1-6 months after stroke):

  • phonological training
  • semantic training

In the chronic stage of stroke recovery
(more than 6 months after stroke):

  • action-embedded therapy
  • speech language therapy-unspecified
  • supported communication
  • technology-assisted training

Studies done with patients who were across the recovery continuum (i.e. acute, subacute and/or chronic):

  • cognitive-behavioral aphasia therapy
  • cognitive-linguistic therapy
  • speech language therapy-unspecified

What can I expect from aphasia therapies?

You can expect to work individually or in small groups with help from your SLP. The SLP might use different approaches such as cards with pictures, electronic devices, stories, video and audio supports, reading and writing material. Your SLP might also provide you with exercises and activities to do in your room or at home, with or without a caregiver/conversational partner.

Do I need to do SLT for a long time?

Research suggests that the timing and intensity of treatment are very important. After a stroke, patients often spend a short time in hospital or a rehabilitation clinic where they receive SLT. They may not continue with SLT when they return home from hospital. However, it is very important to continue with SLT for aphasia.

Research shows that both one-to-one and group therapies are effective for aphasia. The goals of each type of therapy differ. One-to-one therapy may be best for improving speech, whereas group therapy helps with conversation and social skills. So, if you or your family member has aphasia, consider participating in both one-to-one and group therapy if available.

Are there any side effects?

You might experience some side effects from aphasia therapies such as mental fatigue and/or frustration. It is important for your therapist to be aware of any side effects that you might be experiencing so that your treatment regime can be adjusted to better fit your abilities and need

How does aphasia affect my recovery from stroke?

Stroke recovery requires a lot of patience and perseverance from the person who had a stroke and their family/caregivers. If you or your loved one is experiencing aphasia after stroke, the process of recovery might be more frustrating and challenging. It is important to continue with therapies, even if aphasia makes it challenging.

Will my aphasia get better?

Yes. There is evidence that language and communication skills can improve after stroke with different aphasia therapies.

There is also evidence that “higher intensity” SLT (more sessions and/or for a longer duration) can result in greater and/or faster gains.

It is important to remember that the rate at which someone improves, and whether they make a complete or a partial recovery, can vary from one person to another and depends on many individual factors

How long does it take to recover?

The recovery from aphasia can take time. However, there is evidence that speech-language therapy works even in patients who have had the stroke years ago.

My family member has aphasia. How can I help?

Aphasia is stressful for the whole family. Research shows that education sessions are beneficial for family members and friends, as it can increase awareness and knowledge about aphasia. Below are some tips on communicating with people with aphasia.

To help the person with aphasia understand what you are saying:

  • Look at the person when you are speaking to them.
  • Use gestures and facial expressions to help them understand what you are saying.
  • Write down key words. Use a thick black marker and print letters.
  • Draw a picture or symbol of what you are trying to say.
  • Use objects to help get your message across (e.g. if asking the person if they want a drink, hold up a cup).
  • Use yes/no questions.
  • Acknowledge that the person with aphasia is a competent, knowledgeable person who can make decisions, and that they usually know what they want to say, but cannot say it.
  • Speak in a tone of voice appropriate for an adult. Do not sound condescending, or like you are speaking to a child.
  • Communicate one idea at a time. For example, instead of saying:“I will help you get up, showered and dressed and then I am going to take you to the dining room for breakfast but first you have to take your pill.”You might try this:
    • “Here is your pill” (pause and give pill).
    • “First I will help you take a shower” (pause).
    • “Then I will help you get dressed” (pause).
    • “Then I will take you for breakfast.”

The following scenario between a care provider and a patient helps to illustrate the above strategies:

Conversation Strategies used by careprovider
“Mrs. Jones, I want to tell you about an event we have coming up. I think you will be interested.” Comes prepared with a calendar, scrap paper and a black marker.
“This is today.” Points to the date on the calendar.
“On Tuesday…” Points to the date on the calendar and then writes it down.
“…the John Higgins Band is coming to play.” Writes down “John Higgins Band”.
“They are coming here.” Uses hand gestures to indicate the location.
“Do you want to go?” Writes down “Do you want to go?” and points to the resident. Writes down:

Yes / No / I don’t know

and waits for the patient to point to the response.

To help the person with aphasia to get their message across:

  • Encourage the person with aphasia to write down a word or draw if they can.
  • Encourage the person with aphasia to point to something.
  • Ask questions to identify the general topic first and then move onto understanding the details. For example:
    • “Are you talking about your family?”
    • “Are you talking about your daughter?”
    • “Are you wondering if she is coming to visit today?”
  • Ask yes/no questions.
  • Use a written yes/no if needed.
  • If you do not have the time to communicate, explain this and give a time when you will return to finish your conversation. Make sure you do return.
  • Encourage the person with aphasia to use some of the words you have written down to communicate. For example:
    • “I have heard you are a big fan of music?”
    • “What kind of music do you like?”
    • “Opera? … Classical? … Blues?”

Where can I find more information about aphasia?

For further detail about aphasia, please visit these links:

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

This module contains 34 studies, where 21 of them are high quality randomized clinical trials (RCTs), 11 are fair quality RCTs, and two are non-RCTs. The majority of interventions (18 studies) were studied among patients with chronic stroke (i.e. 6 months or more post-stroke).

Overall, we identified different interventions for post-stroke aphasia and those include: constraint-induced aphasia therapy; speech language therapy-unspecified, task-oriented aphasia therapy; semantic / phonological training, action-embedded therapy, intentional gestures and visual gestural cueing, supported communication, technology-assisted training (computer and devices), behavioral aphasia therapy, cognitive linguistic therapy, and narrative aphasia intervention.

Click here to access resources from the Aphasia Institute (Ontario, Canada).

Results Table

View results table

Outcomes

Acute phase - Constraint-induced aphasia therapy

Aphasia
Not Effective
1A

Two high quality RCT (Ciccone et al., 2016; Woldag et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on aphasia severity in patients with acute stroke.

The first high quality RCT (Ciccone et al., 2016) randomized patients to receive CIAT or individual conventional speech language therapy. Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient at post-treatment (4-5 weeks) and follow-up (12 and 26 weeks). No between-group differences were found at any time point.

The second high quality RCT (Woldag et al., 2017) randomized patients to receive CIAT, high-intensity conventional communication group language therapy or low-intensity individual/group speech language therapy. Aphasia was measured by the Aachen Aphasia Test (AAT: 50-item Token test, Repetition, Written language, Naming, Comprehension, Profile level scores) at post-treatment (2 weeks). No between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that CIAT is not more effective than comparison interventions (individual conventional speech language therapy; high-intensity conventional communication group language therapy; low-intensity individual/group speech language therapy) in improving aphasia in patients with acute stroke.

Communication accuracy/efficiency
Not Effective
1B

One high quality RCT (Ciccone et al., 2016) investigated the effect of constraint-induced aphasia therapy (CIAT) on communication accuracy/efficiency in patients with acute stroke. This high quality RCT randomized patients to receive CIAT or individual conventional speech language therapy. Communication accuracy/efficiency was measured by a Discourse Analysis score (percent correct information units produced per minute) at post-treatment (4-5 weeks) and follow-up (12 and 26 weeks). No between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIAT is not more effective than a comparison intervention (individual conventional speech language therapy) in improving communication accuracy/efficiency in patients with acute stroke.

Communication quantity/quality
Effective
1B

One high quality RCT (Woldag et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on communication quantity/quality in patients with acute stroke. This high quality RCT randomized patients to receive CIAT, high-intensity conventional communication group language therapy or low-intensity individual/group speech language therapy. Communication quantity/quality was measured by the Communicative Activity Log (CAL – Quality, Quantity scores) at post-treatment (2 weeks). A significant between-group difference was found on one measure (CAL – Quality score), favoring CIAT vs. high-intensity conventional communication group language therapy. No other significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIAT is more effective than a comparison intervention (high-intensity conventional communication group language therapy) in improving communication quality in patients with acute stroke.
Note: CIAT was not more effective than low-intensity individual/group speech language therapy in improving communication quality; CIAT was not more effective than comparison interventions (high-intensity conventional communication group language therapy) in improving communications quantity.

Quality of life
Not Effective
1B

One high quality RCT (Ciccone et al., 2016) investigated the effect of constraint-induced aphasia therapy (CIAT) on quality of life in patients with acute stroke. This high quality RCT randomized patients to receive CIAT or individual conventional speech language therapy. Quality of life was measured by the Stroke and Aphasia Quality of Life Scale at post-treatment (4-5 weeks) and follow-up (12 and 26 weeks). No between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIAT is not more effective than a comparison intervention (individual conventional speech language therapy) in improving quality of life in patients with acute stroke.

Acute phase - Speech language therapy-unspecified

Aphasia
Not Effective
1B

One high quality RCT (Laska et al., 2011) and one fair quality RCT (Mattioli et al., 2014) investigated the effect of speech language therapy on aphasia in patients with acute stroke.

The high quality RCT (Laska et al., 2011) randomized patients to receive speech language therapy or no treatment. Aphasia was measured by the Norsk Grunntest for Afasi (NGA: Aphasia coefficient) at post-treatment (21 days) and at follow-up (6 months). No significant between group difference was found at either time point.

The fair quality RCT (Mattioli et al., 2014) randomized patients to receive speech language therapy or no treatment. Aphasia was measured by the Aachen Aphasia Test (AAT: Repetition, Naming, Written language, Oral comprehension, Written comprehension, 50-item Token Test, Spontaneous language subtests) at post-treatment (2 weeks) and at follow-up (6 months). Significant between-group differences were found on only two subtests (AAT: Naming, Written language) at post-treatment, favoring speech language therapy vs. no treatment. Improvements were maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that speech language therapy is not more effective than no treatment in improving aphasia in patients with acute stroke.

Carer wellbeing
Not Effective
1B

One high quality RCT (Bowen et al., 2012) investigated the effect of speech language therapy on the wellbeing of carers of patients with acute stroke. This high quality RCT randomized patients to receive speech language therapy or social contact with an untrained conversation partner for 16 weeks. Carer wellbeing was measured by the Carers of Older People in Europe Index (COPE: Negative/Positive impact, Quality of support) at follow-up (6 months post-stroke). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than a comparison intervention (social contact with an untrained conversation partner) in improving the wellbeing of carers of patients with acute stroke.

Functional communication ability
Not Effective
1B

One high quality RCT (Bowen et al., 2012) investigated the effect of speech language therapy on functional communication ability in patients with acute stroke. This high quality RCT randomized patients to receive speech language therapy or social contact with an untrained conversation partner for 16 weeks. Functional communication ability was measured by the Therapy Outcome Measure (TOM: Communicative Activity Scale) at follow-up (6 months post-stroke). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than a comparison intervention (social contact with an untrained conversation partner) in improving functional communication ability in patients with acute stroke.

Self-perception of communication effectiveness
Not Effective
1B

One high quality RCT (Bowen et al., 2012) investigated the effect of speech language therapy on self-perception of communication effectiveness in patients with acute stroke. This high quality RCT randomized patients to receive speech language therapy or social contact with an untrained conversation partner for 16 weeks. Patients’ and carers’ evaluation of patients’ communication effectiveness was measured by the Communication Outcomes After Stroke (COAST) and Carer COAST (respectively) at follow-up (6 months post-stroke). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than a comparison intervention (social contact with an untrained conversation partner) in improving patients’ and carers’ perception of communication effectiveness in patients with acute stroke.

Verbal communication
Not Effective
1B

One high quality RCT (Laska et al., 2011) investigated the effect of speech language therapy on verbal communication in patients with acute stroke. This high quality RCT randomized patients to received speech language therapy or no treatment. Verbal communication skills were measured by the Amsterdam-Nijmegen Everyday Language Test at post-treatment (21 days) and at follow-up (6 months). No significant between group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than no treatment in improving verbal communication in patients with acute stroke.

Acute phase - Very early intervention

Aphasia
Effective
2B

One non-randomized design study (Godecke et al., 2014) investigated the effect of very early intervention on aphasia in patients with acute stroke. This non-randomized design study allocated patients to receive a multimodal intervention or usual care (sample drawn from Godecke et al., 2012 cohort). Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient (percentage maximum potential recovery) at post-treatment (5 weeks) and follow-up (26 weeks post-stroke). Significant between-group differences were found at post-treatment, favoring very early intervention vs. usual care. Improvements were maintained at follow-up.

Conclusion: There is limited evidence (Level 2b) from one non-randomized design study that very early intervention is more effective than a comparison intervention (usual care) in improving aphasia in patients with acute stroke.

Communication accuracy/efficiency
Effective
2B

One non-randomized design study (Godecke et al., 2014) investigated the effect of very early intervention on communication accuracy/efficiency in patients with acute stroke. This non-randomized design study allocated patients to receive a multimodal intervention or usual care (sample drawn from Godecke et al., 2012 cohort). Communication accuracy/efficiency was measured by a Discourse Analysis score at post-treatment (5 weeks) and follow-up (26 weeks post-stroke). A significant between-group difference was found at post-treatment, favoring very early intervention vs. usual care. Improvements were not maintained at follow-up.

Conclusion: There is limited evidence (Level 2b) from one non-randomized design study that very early intervention is more effective than a comparison intervention (usual care) in improving communication accuracy/efficiency in patients with acute stroke.

Subacute phase - Constraint-induced aphasia therapy

Aphasia
Non Effective
1B

One high quality RCT (Sickert et al., 2014) investigated the effect of modified Constraint Induced Aphasia Therapy (mCIAT) on aphasia in patients with subacute stroke. This high quality RCT randomized patients to receive mCIAT or conventional aphasia therapy. Aphasia was measured by the Aachener Aphasia Test (Spontaneous speech, Token Test, Repetition, Written language, Naming, Comprehension) at post-treatment (3 weeks) and follow-up (8 weeks, 1 year). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mCIAT is not more effective that a comparison intervention (conventional therapy) in improving aphasia in patients with subacute stroke.

Communication quantity/quality
Not Effective
1B

One high quality RCT (Sickert et al., 2014) investigated the effect of modified Constraint Induced Aphasia Therapy (mCIAT) on communication quantity/quality in patients with subacute stroke. This high quality RCT randomized patients to receive mCIAT or conventional aphasia therapy. Communication quantity/quality was measured by the Communicative Activity Log (CAL – Quality, Quantity scores: patient/relative scores) at post-treatment (3 weeks) and follow-up (8 weeks, 1 year). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mCIAT is not more effective that a comparison intervention (conventional therapy) in improving communication quantity/quality in patients with subacute stroke.

Subacute phase - Semantic vs. phonological treatment approaches

Language processing
Effective
1B

One high quality RCT (Doesborgh et al., 2004a) compared the effect of semantic vs. phonological intervention approaches on language processingin patients with subacute stroke. This high quality RCT randomized patients to receive semantic (interpretation-focused) or phonological (sound structure focused) treatment approaches. Language processing skills were measured by the Semantic Association Test [semantic measure] and the Psycholinguistic Assessment of Language Processing in Aphasia (PALPA: synonym judgement [semantic measure], nonword repetition, auditory lexical decision [phonological measures]) at post-treatment (10-12 months). A significant between-group difference was found on one phonological measure (PALPA: auditory lexical decision), favoring phonological vs. semantic treatment approach.
Note: A statistically-significant within-group improvement in one semantic measure (Semantic Association Test) was seen following semantic treatment, and an improvement in both phonological measures was seen following phonological treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a phonological treatment approach is more effective than a semantic treatment approach in improving phonological language processing skills in patients with subacute stroke.

Verbal communication
Not Efective
1B

One high quality RCT (Doesborgh et al., 2004a) compared the effect of semantic vs. phonological intervention approaches on verbal communication in patients with subacute stroke. This high quality RCT randomized patients to receive semantic (interpretation-focused) or phonological (sound structure focused) treatment approaches. Verbal communication skills were measured by the Amsterdam Nijmegen Everyday Language Test (ANELT-A: final score, mean improvement) at post-treatment (10-12 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a semantic treatment approach is not more effective than a phonological treatment approach in improving verbal communication in patients with subacute stroke.

Subacute phase - Speech language therapy-unspecified

Carers' perception of patient's language
Not Effective
1B

One high quality RCT (Lincoln et al., 1984) investigated the effect of speech language therapy on carers’ perception of language in patients with subacute stroke. This high quality RCT randomized patients to receive speech language therapy or no treatment. Carer’s perception of patient’s expressive and receptive language was measured by the Speech Questionnaire at mid-treatment (12 weeks) and post-treatment (24 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than no treatment in improving carers’ perception of language of patients with subacute stroke.

Communication
Not Effective
1B

One high quality RCT (Lincoln et al., 1984) investigated the effect of speech language therapy on communication in patients with subacute stroke. This high quality RCT randomized patients to receive speech language therapy or no treatment. Communication skills were measured by the Porch Index of Communicative Ability and the Functional Communication Profile at mid-treatment (12 weeks) and post-treatment (24 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that speech language therapy is not more effective than no treatment in improving communication skills in patients with subacute stroke.

Subacute phase - Task-oriented aphasia therapy

Communication
Not Effective
1B

One high quality RCT (Hartman & Laundau, 1987) investigated the effect of task-oriented aphasia therapy in improving communication in patients with subacute stroke. This high quality RCT randomized patients to receive task-oriented aphasia therapy or nondirective counseling and conversation. Communication skills were measured by the Porch Index of Communicative Ability at post-treatment (6 months) and at follow-up (10 months post-stroke). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that task-oriented aphasia therapy is not more effective than a comparison intervention (nondirective counseling and conversation) in improving communication skills in patients with subacute stroke.

Chronic phase - Action-embedded therapy

Aphasia
Effective
1B

One high quality RCT (Stahl et al., 2016) investigated the effect of action-embedded therapy on aphasia in patients with chronic stroke. This high quality cross-over design RCT randomized patients to receive intensive language action therapy (ILAT) or naming therapy for 6 days, then the other intervention for a further 6 days; participants received no therapy for 6 days between intervention periods. Language was measured by the Aachen Aphasia Test (AAT: mean score, production score) at post-treatment (6 days, 18 days). Significant between-group differences were found on both measures at both post-treatment time points, favoring ILAT vs. naming therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive language action therapy is more effective than a comparison intervention (naming therapy) in improving aphasia in patients with chronic stroke.

Word retrieval response time
Not Effective
2A

One fair quality RCT (Drummond & Rentschler, 1981) investigated the effect of action-embedded therapy on word retrieval response time in patients with chronic stroke. This fair quality RCT randomized patients to receive visual-gestural cueing training or no gesture cueing; both groups received auditory-verbal cueing. Word retrieval response time was measured by the response time to 10 AMERIND Gestural Code nouns and 10 non-AMERIND Gestural Code nouns at post-treatment (2 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that visual-gestural cueing training is not more effective than a comparison intervention (no gesture cueing) in improving word retrieval response time in patients with chronic stroke.

Chronic phase - Communication partner program

Aphasia
Not Effective
2B

One non-randomized study (Lyon et al., 1997) investigated the effect of a communication partner program on aphasia in patients with chronic stroke. This non-randomized study assigned patients and their carers to a communication partner training program with a community volunteer. Aphasia was measured by the Boston Diagnostic Aphasia Examination (BDAE: overall mean percentile) at post-treatment (20 weeks). No significant improvements from pre- to post-treatment were found.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that a communication partner training program with a community volunteer is not effective in improving aphasia in patients with chronic stroke.

Communication
Not Effective
2B

One non-randomized study (Lyon et al., 1997) investigated the effect of a communication partner program on communication in patients with chronic stroke. This non-randomized study assigned patients and their carers to a communication partner training program with a community volunteer. Communication skills were measured by the Communication Abilities in Daily Living (CADL) and the non-standardized Communication Readiness and Use Index (CRUI: patient, carer, communication partner scores) at post-treatment (20 weeks). Significant improvements from pre- to post-treatment were found on the CRUI.
Note: an improvement in communication readiness and use (CRUI) was also seen among patient triads whose treatment was deferred.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that a communication partner training program with a community volunteer is not effective in improving communication in patients with chronic stroke.
Note: However, the program was effective in improving patients, carers’ and communication partners’ reports of communication in patients with chronic stroke.

Participation in conversation
Effective
1B

One high quality RCT (Kagan et al., 2001) investigated the effect of a communication partner program on participation in conversation in patients with chronic stroke. This high quality RCT randomized patients to interact with a conversation partner trained in the “Supported Conversation for Adults with Aphasia” program, or with an untrained volunteer. Participation in conversation was measured by the Measure of Participation in Conversation for Adults with Aphasia (MPCA: Interaction, Transaction scores) at post-treatment (1-day workshop). Significant between-group differences were found on both scores, favoring the “Supported Conversation for Adults with Aphasia” program vs. social interactions with an untrained volunteer.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a communication partner program is more effective than a comparison intervention (social interactions with an untrained volunteer) in improving participation in conversation in patients with chronic stroke.

Well-being
Not Effective
2B

One non-randomized study (Lyon et al., 1997) investigated the effect of a communication partner program on well-being in patients with chronic stroke. This non-randomized study assigned patients and their carers to a communication partner training program with a community volunteer. Well-being was measured by the Affect Balance Scale (ABS) and the non-standardized Psychosocial Wellbeing Index (PWI: patient, carer, communication partner scores) at post-treatment (20 weeks). A significant improvement from pre- to post-treatment was found on the PWI scores.
Note: an improvement in wellbeing (PWI) was also seen among patient triads whose treatment was deferred.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that a communication partner training program with a community volunteer is not effective in improving well-being in patients with chronic stroke.
Note: However, the program was effective in improving patients’, carers’ and communication partners’ reported perception of well-being in patients with chronic stroke.

Chronic phase - Constraint-induced aphasia therapy

Aphasia
Not Effective
1b

One high quality RCT (Kurland et al., 2016) and one fair quality RCT (Maher et al., 2006) investigated the effect of constraint-induced aphasia therapy (CIAT) on aphasia in patients with chronic stroke.

The high quality RCT (Kurland et al., 2016) randomized patients to receive interactive language action therapy – constrained (ILAT- constrained) or a modified version of Promoting Aphasic Communicative Effectiveness – unconstrained (mPACE -unconstrained). Aphasia was measured by the Boston Diagnostic Aphasia Examination (BDAE: Aphasia severity, Auditory comprehension, Sentence repetition, Cookie Theft Description task – changes in content units) at post-treatment (2 weeks). No significant between-group difference was found.

The fair quality RCT (Maher et al., 2006) assigned patients to receive CIAT or mPACE. Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient at post-treatment (2 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that constraint-induced aphasia therapy is not more effective than a comparison intervention (Promoting Aphasic Communicative Effectiveness) in improving aphasia in patients with chronic stroke.

Communication
Not Effective
1B

One high quality RCT (Kurland et al., 2016) investigated the effect of constraint-induced aphasia therapy (CIAT) on communication in patients with chronic stroke. This high quality RCT randomized patients to receive interactive language action therapy – constrained (ILAT-constrained) or a modified version of Promoting Aphasic Communicative Effectiveness – unconstrained (mPACE-unconstrained). Communication skills were measured by the Porch Index of Communicative Abilities at post-treatment (2 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that constraint-induced aphasia therapy is not more effective than a comparison intervention (modified version of Promoting Aphasic Communicative Effectiveness – unconstrained) in improving communication skills in patients with chronic stroke.

Naming
Not Effective
1a

Two high quality RCTs (Szaflarski et al., 2015; Kurland et al., 2016) and two fair quality RCTs (Maher et al., 2006; Nenert et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on naming in patients with chronic stroke.

The first high-quality RCT (Szaflarski et al., 2015) randomized patients to receive CIAT or no treatment for 10 consecutive weekdays. Naming skills were measured by the Boston Naming Test (BNT) at follow-up (1 week and 3 months post-treatment). No significant between-group difference was found.

The second high quality RCT (Kurland et al., 2016) randomized patients to receive interactive language action therapy – constrained (ILAT-constrained) or a modified version of Promoting Aphasic Communicative Effectiveness – unconstrained (mPACE-unconstrained). Naming skills were measured by the Object and Action Naming Battery (objects and verbs/trained and untrained items) and BNT at post-treatment (2 weeks). No significant between-group differences were found.

The first fair quality RCT (Maher et al., 2006) assigned patients to receive CIAT or mPACE. Naming skills were measured by the BNT and Action Naming Test at post-treatment (2 weeks). No significant between-group differences were found.

The second fair quality RCT (Nenert et al., 2017) randomized patients to receive CIAT or no treatment. Naming skills were measured by the BNT at post-treatment (10 days). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and two fair quality RCTs that constraint-induced aphasia therapy is not more effective than comparison interventions (no treatment, Promoting Aphasic Communicative Effectiveness) in improving naming skills in patients with chronic stroke.

Noun recall
Not Effective
2a

One fair quality RCT (Nenert et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on noun recall in patients with chronic stroke. This fair quality RCT (Nenert et al., 2017) randomized patients to receive CIAT or no treatment. Noun recall was measured by a noun recall task at post-treatment (10 days). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that constraint-induced aphasia therapy is not more effective than no treatment in improving noun recall in patients with chronic stroke.

Receptive language
Not Effective
1B

One high quality RCT (Szaflarski et al., 2015) and one fair quality RCT (Nenert et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on receptive language in patients with chronic stroke.

The high quality RCT (Szaflarski et al., 2015) randomized patients to receive CIAT or no treatment for 10 consecutive weekdays. Receptive language skills were measured by the Boston Diagnostic Aphasia Examination (BDAE: Complex ideation subtest) and the Peabody Picture Vocabulary Test III (PPVT-III) at follow-up (1 week and 3 months post-treatment). No significant between-group differences were found.

The fair quality RCT (Nenert et al., 2017) randomized patients to receive CIAT or no treatment. Receptive language skills were measured by the PPVT-IV at post-treatment (10 days). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that constraint-induced aphasia therapy is not more effective than no treatment in improving receptive language skills in patients with chronic stroke.

Subjective communication
Not Effective
1B

One high quality RCT (Szaflarski et al., 2015) and one fair quality RCT (Nenert et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on subjective communication in patients with chronic stroke.

The high quality RCT (Szaflarski et al., 2015) randomized patients to receive CIAT or no treatment for 10 consecutive weekdays. Subjective communication skills (fluency, frequency of use, frequency of misunderstandings) were measured by the Mini-Communicative Activities Log (Mini-CAL) at follow-up (1 week and 3 months post-treatment). A significant between-group difference was found at follow-up (3 months post-treatment), favoring CIAT vs. no treatment.

The fair quality RCT (Nenert et al., 2017) randomized patients to receive CIAT or no treatment. Subjective communication skills were measured by the Mini-CAL at post-treatment (10 days). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that constraint-induced aphasia therapy is not more effective than no treatment in improving subjective communication skills in patients with chronic stroke.
Note: However, CIAT was more effective than no treatment in the long term.

Verbal function/fluency
Not Effective
1b

One high quality RCT (Szaflarski et al., 2015) and one fair quality RCT (Nenert et al., 2017) investigated the effect of constraint-induced aphasia therapy (CIAT) on verbal function and fluency in patients with chronic stroke.

The high quality RCT (Szaflarski et al., 2015) randomized patients to receive CIAT or no treatment for 10 consecutive weekdays. Verbal function/fluency was measured by the Semantic Fluency Test (SFT) and the Controlled Oral Word Association Test (COWAT) at follow-up (1 week and 3 months post-treatment). No significant between-group difference was found.

The fair quality RCT (Nenert et al., 2017) randomized patients to receive CIAT or no treatment. Verbal function/fluency was measured by the SFT and the COWAT (raw score) at post-treatment (10 days). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that constraint-induced aphasia therapy is not more effective than no treatment in improving verbal function/fluency.

Chronic phase - Group communication

Aphasia
Effective
1B

One high quality RCT (Elman & Burnstein-Ellis, 1999) investigated the effect of group communication on aphasia in patients with chronic stroke. This high quality RCT randomized patients to receive group communication treatment or delayed group communication treatment (no treatment). Aphasia was measured by the Western Aphasia Battery-Aphasia Quotient (WAB-AQ) at post-treatment (4 months) and follow-up (5 months). A significant between-group difference was found at post-treatment, favoring group communication treatment vs. no treatment. This between-group difference was not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that group communication is more effective than a comparison intervention (no treatment) in improving aphasia in patients with chronic stroke.

Communication
Effective
1B

One high quality RCT (Elman & Burnstein-Ellis, 1999) investigated the effect of group communication on functional communication in patients with chronic stroke. This high quality RCT randomized patients to receive group communication treatment or delayed group communication treatment (no treatment). Communication skills were measured by the Communicative Abilities in Daily Living Test (CADL) and the Shortened Porch Index of Communicative Ability (SPICA) at post-treatment (4 months) and follow-up (5 months). A significant between-group difference was found on one measure (CADL), favoring group communication treatment vs. no treatment. This between-group difference was not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that group communication is more effective than a comparison intervention (no treatment) in improving communication skills in patients with chronic stroke.

Chronic phase - Intentional gestures

Aphasia
Not Effective
2A

One fair quality RCT (Altmann et al., 2014) investigated the effect of intentional gestures on aphasia in patients with chronic stroke. This fair quality RCT randomized patients to receive intensive anomia treatment using intentional left-hand gestures or intensive anomia treatment without gestures. Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient at post-treatment (3 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that intentional gestures is not more effective than comparison interventions without gestures (intensive anomia treatment) in improving aphasia in patients with chronic stroke

Discourse quantity/quality
Not Effective
2A

One fair quality RCT (Altmann et al., 2014) investigated the effect of intentional gestures on discourse quality/quantity in patients with chronic stroke. This fair quality RCT randomized patients to receive intensive anomia treatment using intentional left-hand gestures or intensive anomia treatment without gestures. Discourse quantity/quality was measured according to Discourse Quantity (Utterances, Words, Verbs, Nouns) and Discourse Quality (Grammatical, Correct information units, Propositions, Utterances with new information) at post-treatment (3 weeks) and follow-up (3 months). A significant between-group difference was found on only one measure (Discourse Quantity: Words) at follow-up, favoring intentional left-hand gestures + intensive anomia treatment vs. intensive anomia treatment alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that intentional gestures is not more effective than comparison interventions without gestures (intensive anomia treatment) in improving discourse quantity/quality in patients with chronic stroke.

Naming and retrieval
Not Effective
2A

Two fair quality RCTs (Altmann et al., 2014; Benjamin et al., 2014) investigated the effect of intentional gestures on naming and retrieval skills in patients with chronic stroke.

The first fair quality RCT (Altmann et al., 2014) randomized patients to receive intensive anomia treatment using intentional left-hand gestures or intensive anomia treatment without gestures. Naming and retrieval skills were measured by the Picture Naming probes, Category-Generation probes, and the Boston Naming Test at post-treatment (3 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

The second fair quality RCT (Benjamin et al., 2014) randomized patients to receive picture naming and category-member generation training using intentional left-hand gestures or picture naming and category-member generation training without gestures. Naming and retrieval skills were measured by the Picture Naming and Category-Generation probes at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that intentional gestures is not more effective than comparison interventions without gestures (intensive anomia treatment, picture naming and category-member generation) in improving naming and retrieval skills in patients with chronic stroke.

Chronic phase - Speech language therapy-unspecified

Aphasia
Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on aphasia in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Aphasia was measured by the Sprachsystematisches APhasieScreening (SAPS: Total, Phonology, Lexicon, Syntax, Language comprehension, Language production scores) at post-treatment (3 weeks) and follow-up (6 months). Significant between-group differences in change scores from baseline to post-treatment were found (SAPS: Total, Lexicon, Syntax, Language comprehension, Language production). A significant difference was found on one measure at follow-up (SAPS: Phonology).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is more effective than no treatment in improving aphasia in patients with chronic stroke.

Functional communication
Not Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on functional communication in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy for 3 weeks or no treatment. Functional communication was measured by the Communication Effectiveness Index at follow-up (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is not more effective than no treatment in improving long-term functional communication in patients with chronic stroke.

Nonverbal learning
Not Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on nonverbal learning in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Nonverbal learning was measured by the Nonverbal Learning Test at post-treatment (3 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is not more effective than no treatment in improving nonverbal learning in patients with chronic stroke.

Quality of life
Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on quality of life in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Quality of life was measured by the Stroke and Aphasia Quality of Life Scale-39 (SAQoL-39 – Total, Physical, Communication, Psychosocial, Energy scores) at post-treatment (3 weeks) and follow-up (6 months). A significant between-group difference in change scores from baseline to post-treatment was found on only one measure (SAQoL-39 – Total score).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is more effective than no treatment in improving quality of life in patients with chronic stroke.

Stroke severity
Not Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on stroke severity in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Stroke severity was measured by the modified Rankin Scale at post-treatment (3 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is not more effective than no treatment in reducing stroke severity in patients with chronic stroke.

Verbal communication
Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on verbal communication in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Verbal communication skills were measured by the Amsterdam Nijmegen Everyday Language Test (ANELT: A-scale, B-scale) at post-treatment (3 weeks) and follow-up (6 months). A significant between-group difference in change scores from baseline to post-treatment was found (ANALT: A-scale).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is more effective than no treatment in improving verbal communication skills in patients with chronic stroke.

Visual attention and executive function
Not Effective
1B

One high quality RCT (Breitenstein et al., 2017) investigated the effect of speech language therapy on visual attention and executive function in patients with chronic stroke. This high quality RCT randomized patients to receive intensive speech language therapy or no treatment. Visual attention and executive function were measured by the Trail Making Test A and B at post-treatment (3 weeks) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive speech language therapy is not more effective than no treatment in improving visual attention and executive function in patients with chronic stroke.

Chronic phase - Technology-assisted training

Aphasia
Conflicting
4

Two fair quality RCTs (Katz & Wertz, 1992; Katz & Wertz, 1997) investigated the effect of technology-assisted training on aphasia in patients with chronic stroke.

The first fair quality RCT (Katz & Wertz, 1992) randomized patients to receive computer reading, non-language computer stimulation or no treatment. Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient (WAB-AQ) at post-treatment (6 months). No significant between-group difference was found.

The second fair quality RCT (Katz & Wertz, 1997) randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Aphasia was measured by the WAB-AQ at post-treatment (6 months). Comparison of computer reading vs. non-language computer stimulation revealed a significant difference favoring computer reading. Comparison of computer reading vs. no treatment revealed a significant difference favouring computer reading.
Note: Comparison of non-language computer stimulation vs. no treatment revealed no significant between-group difference.

Conclusion: There is conflicting evidence (Level 4) from two fair quality RCTs regarding the effect of technology-assisted training on aphasia in patients with chronic stroke. While one fair quality RCT found that computer reading was not more effective than comparison interventions (non-language computer stimulation, no treatment); another fair quality RCT found that computer reading was more effective than comparison interventions (non-language computer stimulation, no treatment) in improving aphasia in patients with stroke.
Note: The larger sample size in the second study might explain the found differences that were not detected in the first study.

Cognition
Not Effective
1b

One high quality RCT (Nobis-Bosch et al., 2011) investigated the effect of technology-assisted training on cognition in patients with chronic stroke. This high quality cross-over design RCT randomized patients to receive intensive language training using the B.A.Bar electronic learning device or nonlinguistic cognitive training for 4 weeks, before crossing over to receive the other intervention for a further 4 weeks. Cognition was measured at post-treatment (4 weeks, 8 weeks) and follow-up (3 months) and included: auditory memory, measured by the Wechesler Memory Scale (auditory digit span); visual memory, measured by the Corsi Block Tapping Test; attention, measured by the Test of Attentional Performance (visual scanning subtest); and pattern recognition, measured by the Thurstone’s Primary Mental Ability Test (pattern recognition from subtest 10). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive language training using the B.A.Bar electronic learning device is not more effective than a comparison intervention (nonlinguistic cognitive training) in improving cognition in patients with chronic stroke.

Communication
Not Effective
1B

One high quality RCT (Nobis-Bosch et al., 2011) and two fair quality RCTs (Katz & Wertz, 1992; Katz & Wertz, 1997) investigated the effect of technology-assisted training on communication in patients with chronic stroke.

The high quality cross-over design RCT (Nobis-Bosch et al., 2011) randomized patients to receive intensive language training using the B.A.Bar electronic learning device or nonlinguistic cognitive training for 4 weeks, before crossing over to receive the other intervention for a further 4 weeks. Communication skills were measured by a non-standardized dialogue test (linguistic score – trained/untrained items; communitive score – trained/untrained items), at post-treatment (4 weeks, 8 weeks) and follow-up (3 months). There were no significant between-group differences at either post-treatment timepoint. Significant between-group differences were found (communicative score – trained/untrained items) at follow-up, favoring the group that received nonlinguistic cognitive training followed by intensive language training using the B.A.Bar electronic learning device.

The first fair quality RCT (Katz & Wertz, 1992) randomized patients to receive computer reading, non-language computer stimulation or no treatment. Communication skills were measured by the Porch Index of Communicative Ability (PICA: Overall score, Reading, Writing, Verbal modalities) at post-treatment (6 months). Comparison of computer reading vs. non-language computer stimulation showed significant between-group differences (PICA: Overall, Writing, Verbal scores), favouring computer reading. Comparison of computer reading vs. no treatment revealed significant differences (PICA: Overall, Verbal scores), favouring computer reading.
Note: Comparison of non-language computer stimulation vs. no treatment revealed no significant differences.

The second fair quality RCT (Katz & Wertz, 1997) randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Communication skills were measured by the PICA (Overall score, Auditory, Verbal, Pantomime, Visual, Reading, Copying, Writing scores) at post-treatment (6 months). Comparison of computer reading vs. non-language computer stimulation revealed significant differences (PICA: Overall, Verbal scores), favoring computer reading. Comparison of computer reading vs. no treatment revealed significant differences (PICA: Overall, Verbal, Pantomime scores), favouring computer reading.
Note: Comparison of non-language computer stimulation vs. no treatment revealed significant between-group differences (PICA: Pantomime score), favouring non-verbal computer stimulation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that technology-assisted training is not more effective than comparison interventions (nonlinguistic cognitive training) in improving communication skills in patients with chronic stroke.
Note: However, two fair quality RCTs found that technology-assisted training is more effective than a comparison intervention (non-language computer stimulation) and no treatment in improving communication skills in patients with chronic stroke. Differences in findings could be attributed to the differences in interventions, study design/duration and/or outcome measures used.

Comprehenstion
Conflicting
4

Two fair quality RCTs (Katz & Wertz, 1997; Thompson et al., 2010) investigated the effect of technology-assisted training on comprehension in patients with chronic stroke.

The first fair quality RCT (Katz & Wertz, 1997) randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Comprehension was measured by the Western Aphasia Battery – Comprehension subtest at post-treatment (6 months). No significant between-group difference was found.

The second fair quality RCT (Thompson et al., 2010) randomized patients to receive computer-automated Treatment of Underlying Forms (TUF), clinician-administered TUF or no treatment. Comprehension was measured by the Comprehension Probe (CP: Object relatives, Object clefts, Object wh-questions) and the Northwestern Assessment of Verbs and Sentences – Sentence Comprehension Test (NAVS-SCT: Object relatives, Object wh-questions, Subject relatives, Subject wh-questions) at post-treatment (5 weeks). Significant between-group differences were seen (CP – Object relatives; NAVS-SCT: Objects relatives), favoring the computer-automated TUF vs. no treatment. There were no significant differences between computer-automated and clinician-administered TUF.
Note: Differences between clinician-administered TUF and no treatment were not reported.

Conclusion: There is conflicting evidence (Level 4) from two fair quality RCTs regarding the effects of technology-assisted training on comprehension in patients with chronic stroke. While one fair quality RCT found that computer reading is not more effective than comparison interventions (non-language computer stimulation, no treatment), another fair quality RCT found that a computer-automated Treatment of Underlying Forms program is more effective than no treatment in improving comprehension in patients with chronic stroke.
Note: Differences in findings could be attributed to the difference in the interventions, study design/duration and/or outcome measures used.

Naming
Conflicting
4

Two high quality RCTs (Doesborgh et al., 2004b; Palmer et al., 2012) and one fair quality RCT (investigated the effect of technology-assisted training on naming skills in patients with chronic stroke.

The first high quality RCT (Doesborgh et al., 2004b) randomized patients to receive a multicue computer training program or no treatment. Naming skills were measured by the Boston Naming Test at post-treatment (2 months). No significant between group difference was found.

The second high quality RCT (Palmer et al., 2012) randomized patients to receive computer treatment or no treatment; all patients received usual care. Naming skills were measured by the Object and Action Naming Battery at post-treatment (5 months) and follow-up (8 months). A significant between-group difference was found at post-treatment, favoring computer treatment vs. no treatment. Results did not remain significant at follow-up.

The fair quality RCT (Katz & Wertz, 1997) randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Word finding and semantic retrieval processes were measured by the Western Aphasia Battery – Naming scores at post-treatment (6 months). No between-group difference was found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of technology-assisted training on naming skills in patients with chronic stroke. While one high quality RCT and one fair quality RCT found that computer training programs were not more effective than comparison interventions (no treatment, non-language computer stimulation), another high quality RCT found that a computer program was more effective than no treatment.
Note: The differences in findings may be attributed to the differences in the interventions, design study/duration (2 vs. 5 months), and/or outcome measures used.

Reading comprehension
Not Effective
2A

One fair quality RCT (Katz & Wertz, 1992) investigated the effect of technology-assisted training on reading comprehension in patients with chronic stroke. This fair quality RCT randomized patients to receive computer reading, non-language computer stimulation or no treatment. Reading comprehension was measured by the C-CAT (a non-standardized assessment comprising 232 items from the computer reading program) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer reading is not more effective than comparison interventions (non-language computer stimulation, no treatment) in improving reading comprehension in patients with chronic stroke.

Repetition
Effective
2A

One fair quality RCT (Katz & Wertz, 1997) investigated the effect of technology-assisted training on repetition in patients with chronic stroke. This fair quality RCT randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Repetition was measured by the Western Aphasia Battery – Repetition score at post-treatment (6 months). Comparison of computer reading vs. non-language computer stimulation revealed a significant difference, favoring computer reading. Comparison of computer reading vs. no treatment revealed a significant difference, favouring computer reading.
Note: Comparison of non-language computer stimulation vs. no treatment revealed a significant between-group difference, favouring non-verbal computer stimulation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer reading is more effective than comparison interventions (non-language computer stimulation, no treatment) in improving repetition in patients with chronic stroke.

Sentence production
Not Effective
2A

One fair quality RCT (Thompson et al., 2010) investigated the effect of technology-assisted training on comprehension in patients with chronic stroke. This fair quality RCT randomized patients to receive computer-automated Treatment of Underlying Forms (TUF), clinician-administered TUF or no treatment. Comprehension was measured by the Production Probe (PP: Object relatives, Object clefts, Object wh-questions), the Northwestern Assessment of Verbs and Sentences – Sentence Production Priming Test (NAVS-SPPT: Object relatives, Object wh-questions, Subject relatives, Subject wh-questions), and the Cinderella narratives (CN: Mean length of utterance, Words per minute, Complex to simple sentence ratio, Noun to verb ratio, Open to closed class ratio, % grammatical sentences, % verbs with correct arguments) at post-treatment (5 weeks). Comparison of computer-automated TUF vs. no treatment revealed significant between-group differences (PP: Object relatives, Object clefts; NAVS-SPPT – Objects relatives), favoring computer-automated TUF. There were no significant differences between computer-automated and clinician-administered TUF.
Note: Differences between clinician-administered TUF and no treatment were not reported.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-automated Treatment of Underlying Forms is not more effective than no treatment in improving sentence production in patients with chronic stroke.
Note: significant between-group differences were seen in only 2/3 of 7/14 measures

Spontaneous speech
Not Effective
1B

One high quality RCT (Nobis-Bosch et al., 2011) and one fair quality RCT (Katz & Wertz, 1997) investigated the effect of technology-assisted training on spontaneous speech in patients with chronic stroke.

The high quality RCT (Nobis-Bosch et al., 2011) randomized patients to receive intensive language training using the B.A.Bar electronic learning device or nonlinguistic cognitive training for 4 weeks, before crossing over to receive the other intervention for a further 4 weeks. Spontaneous speech was measured by a semi-standardized interview at post-treatment (4 weeks, 8 weeks) and follow-up (3 months). No significant between-group differences were found at any time point.

The fair quality RCT (Katz & Wertz, 1997) randomized patients to receive computer reading, non-language computer stimulation, or no treatment. Spontaneous speech was measured by the Western Aphasia Battery – Spontaneous speech score at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that technology-assisted training is not more effective than comparison interventions (nonlinguistic cognitive training, non-language computer stimulation, no treatment) in improving spontaneous speech in patients with chronic stroke.

Verbal communication
Not Effective
1A

Two high quality RCTs (Doesborgh et al., 2004b; Nobis-Bosch et al., 2011) investigated the effect of technology-assisted training on verbal communication in patients with chronic stroke.

The first high quality RCT (Doesborgh et al., 2004b) randomized patients to receive a multicue computer training program or no treatment. Verbal communication was measured by the Amsterdam Nijmegen Everyday Language Test – Scale A at post-treatment (2 months). No significant between group difference was found.

The second high quality cross-over design RCT (Nobis-Bosch et al., 2011) randomized patients to receive intensive language training using the B.A.Bar electronic learning device or nonlinguistic cognitive training for 4 weeks, before crossing over to receive the other intervention for a further 4 weeks. Verbal communication was measured by the Amsterdam Nijmegen Everyday Language Test at post-treatment (4 weeks, 8 weeks) and follow-up (3 months). No significant between-group difference was found at any time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that technology-assisted training is not more effective than comparison interventions (no treatment, nonlinguistic cognitive training) in improving verbal communication in patients with chronic stroke.

Verbal fluency
Not Effective
1B

One high quality RCT (Nobis-Bosch et al., 2011) investigated the effect of technology-assisted training on verbal fluency in patients with chronic stroke. This high quality RCT randomized patients to receive intensive language training using the B.A.Bar electronic learning device or nonlinguistic cognitive training for 4 weeks, before crossing over to receive the other intervention for a further 4 weeks. Verbal fluency was measured by the Word Fluency Test (Food, Animals) at post-treatment (4 weeks, 8 weeks) and follow-up (3 months). No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that intensive language training using the B.A.Bar electronic learning device is not more effective than a comparison intervention (nonlinguistic cognitive training) in improving verbal fluency in patients with chronic stroke.

Phase not specific to one period - Cognitive behavior language therapy

Communication
Effective
1B

One high quality RCT (Akabogu et al., 2019) investigated the effect of cognitive behavior language therapy (CBLT) on communication in patients with stroke. This high quality RCT randomized patients (stage of stroke recovery not specified) to receive CBLT or no treatment. Communication skills were measured by the Porch Index of Communicative Ability at post-treatment (10 weeks) and follow-up (3 months). Significant between-group differences were found at both time points, favoring CBLT vs. no treatment.
Note: In this study, CBLT principles were combined with targeted, conventional speech therapy aimed to reduce aphasia by helping patients to use their remaining language abilities; restore language abilities; and learn alternative communication ways (e.g. gestures, pictures, or use of electronic devices).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CBLT is more effective than no treatment in improving communication skills in patients with stroke.

Unhelpful thoughts and beliefs
Effective
1B

One high quality RCT (Akabogu et al., 2019) investigated the effect of cognitive behavior language therapy (CBLT) on unhelpful thoughts and beliefs in patients with stroke. This high quality RCT randomized patients (stage of stroke recovery not specified) to receive CBLT or no treatment. Speech-language unhelpful thoughts and beliefs were measured by Speech-Language Unhelpful Thoughts and Beliefs Scale at post-treatment (10 weeks) and follow-up (3 months). Significant between-group differences were found at both time points, favoring CBLT vs. no treatment.
Note: In this study, CBLT principles were combined with targeted, conventional speech therapy aimed to reduce aphasia by helping patients to use their remaining language abilities; restore language abilities; and learn alternative communication ways (e.g. gestures, pictures, or use of electronic devices).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CBLT is more effective than no treatment in reducing unhelpful thoughts and beliefs in patients with stroke.

Phase not specific to one period - Cognitive-linguistic training

Communication (understandability)
Not Effective
1B

One high quality RCT (de Jong-Hagelstein et al., 2011) investigated the effect of cognitive-linguistic training on communication (understandability) in patients with acute/subacute stroke. This high quality RCT randomized patients to receive cognitive-linguistic training or communicative treatment (compensatory strategies and use of residual language skills). Communication (understandability) was measured by the Amsterdam-Nijmegen Everyday Language Test Scale A: Understandability (ANELT-A: Final score, Mean improvement, Severity category) at mid-treatment (3 months) and post-treatment (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive-linguistic training is not more effective than a comparison intervention (communicative treatment) in improving communication (understandability) in patients with stroke.

Fluency
Effective
1B

One high quality RCT (de Jong-Hagelstein et al., 2011) investigated the effect of cognitive-linguistic training on fluency in patients with acute/subacute stroke. This high quality RCT randomized patients to receive cognitive-linguistic training or communicative treatment (compensatory strategies and use of residual language skills). Fluency was measured by the Letter Fluency Task (LFT), Semantic Association Test (SAT), Semantic Word Fluency (SWF) at mid-treatment (3 months) and post-treatment (6 months). A significant between-group difference was found in one measure at mid-treatment (SWF) and in one measure (LFT) at post-treatment, favoring cognitive-linguistic training vs. communicative treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive-linguistic training is more effective than a comparison intervention (communicative treatment) in improving fluency in patients with stroke.

Language processing
Not Effective
1B

One high quality RCT (de Jong-Hagelstein et al., 2011) investigated the effect of cognitive-linguistic training on language processing in patients with acute/subacute stroke. This high quality RCT randomized patients to receive cognitive-linguistic training or communicative treatment (compensatory strategies and use of residual language skills). Language processing skills were measured by the Psycholinguistic Assessment of Language Processing in Aphasia (PALPA: Semantic association with low imageability words, Nonword repetition, Auditory lexical decision) at mid-treatment (3 months) and post-treatment (6 months). mid-treatment (3 months) and post-treatment (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive-linguistic training is not more effective than a comparison intervention (communicative treatment) in improving language processing skills in patients with stroke.

Phase not specific to one period - Narrative aphasia intervention

Discourse abilities
Not Effective
1B

One high quality RCT (Whitworth et al., 2014) investigated the effect of narrative aphasia intervention on discourse abilities in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Novel Approach to Real-life communication – Narrative Intervention in Aphasia (NARNIA) or usual care. Discourse abilities were measured at (i) word-level by the Pyramid and Palmtrees Test, Kissing and Dancing Test, the Object and Action Naming Battery (Noun retrieval, Verb retrieval), and the Northwestern Assessment of Verbs and Sentences (NAVS – Verb comprehension, Verb naming); (ii) sentence-level by the NAVS (Sentence Comprehension Test, Argument Structure Production Test) and the Sentence Generation Test; and (iii) discourse level by the Curtin University Discourse Protocol – Everyday Discourse (Overall Input: number of utterances; Single Word Level: heavy verbs, light verbs, mental verbs; Sentence Level: two arguments, three arguments, thematic; Discourse: orientation, body, conclusion) at post-treatment (5 weeks). A significant between-group differences was found in only one measure (Everyday Discourse -Discourse: orientation), favoring NARNIA vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that narrative aphasia intervention is not more effective than a comparison intervention (usual care) in improving discourse abilities in patients with subacute/chronic stroke.

Phase not specific to one period - Speech language therapy-unspecified

Abstract reasoning
Effective
2A

One fair quality RCT (Lincoln et al., 1982) investigated the effect of speech language therapy (SLT) on abstract reasoning in patients with stroke. This fair quality cross-over design RCT randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Abstract reasoning was measured by the Raven’s Progressive Matrices at post-treatment (4 weeks). A significant between-group difference was found, favoring SLT vs. attention placebo. There were no significant differences between SLT and operant conditioning.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech language therapy is more effective than a comparison intervention (attention placebo treatment) in improving abstract reasoning in patients with stroke.
Note: SLT was not more effective than operant conditioning.

Aphasia
Not Effective
2A

One fair quality RCT (Lincoln et al., 1982) investigated the effect of speech-language therapy (SLT) on aphasia in patients with stroke. This fair quality cross-over design RCT randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Aphasia was measured by the Token Test – short version at post-treatment (4 weeks). No significant between-group differences were found.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech language therapy is not more effective than comparison interventions (attention placebo treatment, operant conditioning) in improving aphasia in patients with stroke.

Communication
Not Effective
2A

Two fair quality RCTs (David et al., 1982; Lincoln et al., 1982) investigated the effect of speech language therapy (SLT) on communication in patients with stroke.

The first fair quality RCT (David et al., 1982) randomized patients with subacute/chronic stroke to receive SLT or language stimulation by untrained volunteers. Communication skills were measured by the Functional Communication Profile at different treatment intervals (1, 2, 3, 4 weeks of treatment) and at post-treatment (15-20 weeks). No significant between-group difference was found at any time point.

The second fair quality cross-over design RCT (Lincoln et al., 1982) randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Communication skills were measured by the Porch Index of Communicative Ability at post-treatment (4 weeks). No significant between-group differences were found.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that speech language therapy is not more effective than comparison interventions (stimulation and support by untrained volunteers, operant conditioning, non-specific attention placebo treatment) in improving communication skills in patients with stroke.

Fluency
Not Effective
2A

One fair quality RCT (Lincoln et al., 1982) investigated the effect of speech language therapy (SLT) on fluency in patients with stroke. This fair quality cross-over design RCT randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Fluency was measured by the Fluency (Food/Countries) and Picture Description tasks at post-treatment (4 weeks). No significant between-group differences were found.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech language therapy is not more effective than comparison interventions (attention placebo treatment, operant conditioning) in improving fluency in patients with stroke.

Functional speech
Not Effective
2A

One fair quality RCT (Lincoln et al., 1982) investigated the effect of speech language therapy (SLT) on functional speech in patients with stroke. This fair quality cross-over design RCT randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Functional Speech was measured by the Speech Questionnaire at post-treatment (4 weeks). A significant between-group difference in change scores was found, favoring attention placebo vs. SLT. There were no significant differences between SLT and operant conditioning.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech language therapy is not more effective than a comparison intervention (attention placebo treatment, operant conditioning) in improving functional speech in patients with stroke.

Naming
Not Effective
2A

One fair quality RCT (Lincoln et al., 1982) investigated the effect of speech language therapy (SLT) on functional speech in patients with stroke. This fair quality cross-over design RCT randomized patients with subacute/chronic stroke to receive (i) SLT or (ii) operant training or attention placebo for 4 weeks; participants then crossed over to receive the other intervention for a further 4 weeks (see group assignment below). Functional Speech was measured by the Speech Questionnaire at post-treatment (4 weeks). A significant between-group difference in change scores was found, favoring attention placebo vs. SLT. There were no significant differences between SLT and operant conditioning.
Note: Participants were assigned to 1 of 4 groups – Group A (SLT then attention placebo), Group B (attention placebo then SLT), Group C (SLT then operant conditioning), Group D (operant conditioning then SLT).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech language therapy is not more effective than a comparison intervention (attention placebo treatment, operant conditioning) in improving functional speech in patients with stroke.

Phase not specific to one period - Technology-assisted training

Aphasia
Not Effective
1B

One high quality RCT (Kesav et al., 2017) investigated the effect of technology-assisted training on aphasia in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive computer-based language rehabilitation therapy or no additional treatment; both groups received conventional speech language therapy. Aphasia was measured by the Western Aphasia Battery – Aphasia Quotient at post-treatment (4 weeks) and follow-up (3 months). A significant between-group difference was found at both time points, favoring no additional treatment vs. computer-based language rehabilitation therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that technology-assisted training is not more effective than a comparison intervention (conventional speech language therapy alone) in improving aphasia in patients with stroke.
Note: The high quality RCT found that computer-based language rehabilitation therapy + conventional speech language therapy was less effective than speech language therapy alone.

References

Reference list:

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  • Mattioli, F., Ambrosi, C., Mascaro, L., Scarpazza, C., Pasquali, P., Frugoni, M., … & Gasparotti, R. (2014). Early aphasia rehabilitation is associated with functional reactivation of the left inferior frontal gyrus: a pilot study. Stroke, 45(2), 545-552.

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  • Nenert, R., Allendorfer, J. B., Martin, A. M., Banks, C., Ball, A., Vannest, J., … & Szaflarski, J. P. (2017). Neuroimaging Correlates of Post-Stroke Aphasia Rehabilitation in a Pilot Randomized Trial of Constraint-Induced Aphasia Therapy. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 23, 3489.

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  • Palmer, R., Enderby, P., Cooper, C., Latimer, N., Julious, S., Paterson, G., … & Delaney, A. (2012). Computer therapy compared with usual care for people with long-standing aphasia poststroke: a pilot randomized controlled trial. Stroke, 43(7), 1904-1911.

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  • Stahl, B., Mohr, B., Dreyer, F. R., Lucchese, G., & Pulvermüller, F. (2016). Using language for social interaction: communication mechanisms promote recovery from chronic non-fluent aphasia. Cortex, 85, 90-99.

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  • Whitworth, A., Leitao, S., Cartwright, J., Webster, J., Hankey, G. J., Zach, J., … & Wolz, V. (2015). NARNIA: A new twist to an old tale. A pilot RCT to evaluate a multilevel approach to improving discourse in aphasia. Aphasiology, 29(11), 1345-1382.

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  • Woldag, H., Voigt, N., Bley, M., & Hummelsheim, H. (2017). Constraint-induced aphasia therapy in the acute stage: What is the key factor for efficacy? A randomized controlled study. Neurorehabilitation and Neural Repair, 31(1), 72-80.

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Excluded Studies:

  • Bonifazi, S., Tomaiuolo, F., Altoè, G., Ceravolo, M. G., Provinciali, L., & Marangolo, P. (2013). Action observation as a useful approach for enhancing recovery of verb production: new evidence from aphasia. Eur. J. Phys. Rehabil. Med, 49, 473-481.

    Reason for exclusion: not a RCT.

  • Brady, M. C., Kelly, H., Godwin, J., & Enderby, P. (2012). Speech and language therapy for aphasia following stroke. Cochrane database of systematic reviews, (5).

    Reason for exclusion: review; all references of this review were verified for inclusion/exclusion in the present module.

  • Cherney, L. R. (2010). Oral reading for language in aphasia (ORLA): Evaluating the efficacy of computer-delivered therapy in chronic nonfluent aphasia. Topics in Stroke Rehabilitation, 17(6), 423-431.

    Reason for exclusion: both groups received therapy; mode of delivery differed (computer vs. therapist).

  • Crerar, M. A., Ellis, A. W., & Dean, E. C. (1996). Remediation of sentence processing deficits in aphasia using a computer-based microworld. Brain and Language, 52(1), 229-275.

    Reason for exclusion: both groups received therapy, no control group.

  • Des Roches, C. A., & Kiran, S. (2017). Technology-based rehabilitation to improve communication after acquired brain injury. Frontiers in neuroscience, 11, 382

    Reason for exclusion: review; all references of this review were verified for inclusion/exclusion in the present module.

  • Dignam, J., Copland, D., McKinnon, E., Burfein, P., O’brien, K., Farrell, A., & Rodriguez, A. D. (2015). Intensive versus distributed aphasia therapy: a nonrandomized, parallel-group, dosage-controlled study. Stroke, 46(8), 2206-2211.

    Reason for exclusion: both groups received therapy, only intensity varied.

  • Ferguson, N. F., Evans, K., & Raymer, A. M. (2012). A comparison of intention and pantomime gesture treatment for noun retrieval in people with aphasia. American Journal of Speech-Language Pathology, 21(2), S126-S139.

    Reason for exclusion: not a RCT.

  • Hinckley, J. J., Patterson, J. P., & Carr, T. H. (2001). Differential effects of context-and skill-based treatment approaches: Preliminary findings. Aphasiology, 15(5), 463-476.

    Reason for exclusion: all groups received therapy; no control group.

  • Humphreys, I., Thomas, S., Phillips, C., & Lincoln, N. (2015). Cost analysis of the Communication and Low Mood (CALM) randomised trial of behavioural therapy for stroke patients with aphasia. Clinical rehabilitation, 29(1), 30-41

    Reason for exclusion: cost-effectiveness report, no outcome of interest.

  • Godecke, E., Hird, K., Lalor, E. E., Rai, T., & Phillips, M. R. (2012). Very early poststroke aphasia therapy: a pilot randomized controlled efficacy trial. International Journal of Stroke, 7(8), 635-644.

    Reason for exclusion: both groups received therapy, only intensity differed.

  • Godecke, E., Armstrong, E. A., Rai, T., Middleton, S., Ciccone, N., Whitworth, A., … & Cadilhac, D. A. (2016). A randomized controlled trial of very early rehabilitation in speech after stroke.

    Reason for exclusion: study protocol.

  • Latimer, N. R., Dixon, S., & Palmer, R. (2013). Cost-utility of self-managed computer therapy for people with aphasia. International journal of technology assessment in health care, 29(4), 402-409.

    Reason for exclusion: cost-analysis report, no outcome of interest.

  • (2013). UK: British Aphasiology Society, 2007: 67–8.∗ Martins IP, Leal G, Fonseca I, Farrajota L, Aguiar M, Fonseca J, et al. A randomized, rater-blinded, parallel trial of intensive speech therapy in sub-acute post-stroke aphasia: the SP-IR-IT study. International Journal of Language and Communication Disorders, 48(4), 421-31.

    Reason for exclusion: both groups received therapy, only intensity varied.

  • Rochon, E., Laird, L., Bose, A., & Scofield, J. (2005). Mapping therapy for sentence production impairments in nonfluent aphasia. Neuropsychological Rehabilitation, 15(1), 1-36.

    Reason for exclusion: not a RCT (n=5 patients).

  • Thomas, S. A., Walker, M. F., Macniven, J. A., Haworth, H., & Lincoln, N. B. (2013). Communication and Low Mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia. Clinical rehabilitation, 27(5), 398-408.

    Reason for exclusion: study included in the Depression module.

  • Szelag, E., Lewandowska, M., Wolak, T., Seniow, J., Poniatowska, R., Pöppel, E., & Szymaszek, A. (2014). Training in rapid auditory processing ameliorates auditory comprehension in aphasic patients: a randomized controlled pilot study. Journal of the neurological sciences, 338(1-2), 77-86.

    Reason for exclusion: both groups received computerized training; no control group.

  • Smith, D. S., Goldenberg, E., Ashburn, A. E., Kinsella, G., Sheikh, K., Brennan, P. J., … & Reeback, J. S. (1981). Remedial therapy after stroke: a randomised controlled trial. Br Med J (Clin Res Ed), 282(6263), 517-520.

    Reason for exclusion: no outcome of interest.

  • Van der Meulen, I., van de Sandt-Koenderman, W. M. E., Heijenbrok-Kal, M. H., Visch-Brink, E. G., & Ribbers, G. M. (2014). The efficacy and timing of melodic intonation therapy in subacute aphasia. Neurorehabilitation and neural repair, 28(6), 536-544.

    Reason for exclusion: study included in the “Music Therapy” module.

  • Varley, R., Cowell, P. E., Dyson, L., Inglis, L., Roper, A., & Whiteside, S. P. (2016). Self-administered computer therapy for apraxia of speech: two-period randomized control trial with crossover. Stroke, 47(3), 822-828.

    Reason for exclusion: the intervention was designed for apraxia of speech and not aphasia.

  • Wan, C. Y., Zheng, X., Marchina, S., Norton, A., & Schlaug, G. (2014). Intensive therapy induces contralateral white matter changes in chronic stroke patients with Broca’s aphasia. Brain and language, 136, 1-7.

    Reason for exclusion: study included in the “Music Therapy” module.

  • Wenke, R., Lawrie, M., Hobson, T., Comben, W., Romano, M., Ward, E., & Cardell, E. (2014). Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting. International journal of speech-language pathology, 16(3), 250-259.

    Reason for exclusion: not a RCT.

  • Wilssens, I., Vandenborre, D., van Dun, K., Verhoeven, J., Visch-Brink, E., & Mariën, P. (2015). Constraint-induced aphasia therapy versus intensive semantic treatment in fluent aphasia. American Journal of Speech-Language Pathology, 24(2), 281-294.

    Reason for exclusion: both groups received therapy.

  • Whiteside, S. P., Inglis, A. L., Dyson, L., Roper, A., Harbottle, A., Ryder, J., … & Varley, R. A. (2012). Error reduction therapy in reducing struggle and group behaviours in apraxia of speech. Neuropsychological Rehabilitation, 22(2), 267-294.

    Reason for exclusion: the intervention was designed for apraxia of speech and not aphasia.

  • Woolf, C., Caute, A., Haigh, Z., Galliers, J., Wilson, S., Kessie, A., … & Marshall, J. (2016). A comparison of remote therapy, face to face therapy and an attention control intervention for people with aphasia: a quasi-randomised controlled feasibility study. Clinical Rehabilitation, 30(4), 359-373

    Reason for exclusion: both groups received therapy; mode of delivery was different.

  • Zhang, J., Yu, J., Bao, Y., Xie, Q., Xu, Y., Zhang, J., & Wang, P. (2017). Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials. PloS one, 12(8), e0183349.

    Reason for exclusion: review; all references of this review were verified for inclusion/exclusion in the present module.

Fatigue

Evidence Reviewed as of before: 28-08-2019
Author(s)*: Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Fatigue is a multidimensional, motor-perceptive, cognitive and emotional experience. It is described as “a feeling of early exhaustion with weariness, lack of energy and aversion to effort that develops during physical or mental activity and is usually not ameliorated by rest” (Staub & Bogousslavsky, 2001). Post-stroke fatigue can be distinguished into three types:

1) Physical fatigue (i.e. inability to perform activities at physical lengths and intensities);
2) Cognitive fatigue (i.e. inability to perform activities at concentration, multitasking and/or cognitive load stressors lengths and intensities); and
3) Emotional fatigue (i.e. getting tired when facing demanding interactions or relationships) (Terrill, Schwartz & Belagaje, 2018).

Post-stroke fatigue is a prevalent stroke consequence, affecting more than 50% of stroke survivors (Cumming et al. 2016). Prevalence cannot be explained by type of stroke, side of stroke or lesion location. Prevalence is also not associated to stroke severity, meaning that prevalence is the same in mild stroke as compared to severe stroke (Acciarresi et al., 2014). Fatigue is associated with depressive symptoms but can be present without depression. Its association to cognitive deficits and gender remains unclear. However, higher levels of fatigue are found to be associated with female sex, depression, longer post-stroke time period and greater disability (Cumming et al., 2018).

A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

Patient/Family Information

Author: Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT

Since my stroke I feel tired. Am I normal?

Fatigue is common in patients with stroke. Approximately 50% of stroke survivors will experience fatigue after having a stroke, no matter what the severity of the stroke is.

What is fatigue after stroke?

Fatigue is a feeling of early tiredness, lack of energy and aversion to effort. Fatigue occurs during or after activity that is physically demanding, mentally demanding (i.e. requiring attention and concentration) or emotionally demanding (e.g. conflict with another person). The main difference with regular fatigue is that post-stroke fatigue usually does not get better as fast with rest.

Are there different types of fatigue?

Fatigue after stroke is usually distinguished into three types: 1) physical, 2) mental or cognitive, and 3) emotional.

Physical fatigue is when a person is unusually tired after physical activity, or is unable to perform a physical activity that requires more effort or strength (e.g. walking, going up the stairs) or for a long period of time.

Mental or cognitive fatigue is when a person is unusually tired after or unable to perform an activity that requires attention, concentration or multitasking (e.g. reading, following a movie).

Emotional fatigue is when a person is unusually tired after difficult interactions or conflicts with close ones (e.g. marital conflict, being uncomfortable with someone, difficulty managing emotions).

When would fatigue appear after a stroke?

Fatigue after stroke can appear at different times. Some people experience fatigue shortly after the stroke. Others experience fatigue much later after stroke, even 1 year after stroke.

Is fatigue caused by my stroke?

It is possible that the fatigue you are experiencing is an effect of your stroke. Here is one possible explanation:

Injury to your brain

There are debates on whether the site of the lesion (stroke location) is related to symptoms of fatigue. Some research shows that people who have a stroke in specific parts of the brain (basal ganglia, internal capsule, brain stem, thalamus) are more likely to experience post-stroke fatigue. Other research argues that it is the number of strokes that matter, where fatigue is more common in people who have had several strokes rather than in those who had a stroke for the first time.

How do I know if I have post-stroke fatigue? What are the common signs of fatigue after a stroke?

People who have fatigue after stroke share some common traits such as:

  • Low energy
  • Feeling weary soon after starting a physical activity (e.g. walking, exercise), an activity that is mentally demanding (e.g. reading, social event) or an activity that is emotionally demanding (e.g. conflict with another person).
  • Feeling a loss of self-control
  • Feeling emotional instability
  • Feeling of tiredness that becomes greater during physical exercise, during activities that require concentration and/or with stress.

Is it easy to detect fatigue after a stroke?

It is often easy to detect fatigue in a person that has had a stroke. However, it can be difficult to identify the type of fatigue you are experiencing and what causes you to feel tired. Your rehabilitation therapist may often ask about your level of fatigue. However, sometimes people who had a stroke have problems speaking or understanding words; this makes it more difficult to share information about fatigue symptoms.

How is the diagnosis of fatigue after a stroke made?

Your therapist may ask you a series of questions or have you or your caregiver fill out a questionnaire. This will help to identify presence of fatigue.

Are there different kinds of therapies for fatigue?

There are many different therapies available for fatigue after stroke. This module includes the following interventions:

  • Mindfulness-based stress reduction (MBSR): a program that helps you to calm you mind and body to help cope with illness, pain, and stress.
  • Inspiratory muscle training (IMT): breathing exercises using a breathing device.
  • Game-based team therapy: playing games in groups that are competitive in nature (e.g. playing ball with scores).
  • Multimodal interventions: rehabilitation that combines physical exercises and cognitive exercises together.
  • Psychoeducation: education, advice, recommendations, and strategies to help change your thoughts and behavior.

There is no known ‘cure’ for post-stroke fatigue. However, when we asked individuals who have had a stroke for their key strategies to cope with fatigue post-stroke, they told us:

  • To accept that you may need to reduce the frequency or intensity of an activity;
  • To plan rest periods into your daily routine;
  • To organise your environment and routine;
  • To conserve your energy when doing everyday activities by making a task simpler;
  • To identify the type of fatigue you are prone to and the activities that trigger your fatigue;
  • To prioritise activities that are meaningful to you and your well-being;
  • To communicate with your close-ones about your level of fatigue;
  • To engage in planned exercise such as aerobics to increase endurance;
  • To practice good sleep patterns.

What fatigue therapies work for stroke?

Fatigue therapies have been examined using high and fair quality research studies. Some therapies were shown to improve mental fatigue and other important domains such as independence in self-care activities, depression, sleep, endurance and respiratory function in some patients after stroke.

In particular, for patients with chronic stroke (more than 6 months after stroke), mindfulness-based stress reduction therapy has been shown to be useful to improve mental fatigue, depression, anxiety, and cognitive abilities (e.g. attention).

For patients with stroke across the recovery continuum (acute, subacute and/or chronic), inspiratory muscle training, game-based team therapy, and multimodal interventions have been shown to be useful to improve fatigue, independence in everyday activities (e.g. dressing, walking), respiratory function (e.g. inspiration and expiration lung capacities), depression, and sleep.

What can I expect in terms of therapy for fatigue?

Your therapist will discuss with you what fatigue therapy is most suitable for you. How often and for how long the therapy is provided for depends on the nature of therapy.

Who provides the treatment?

Different health-care providers can administer fatigue therapies: occupational therapists, physiotherapists, psychologists, neuropsychologists and nurses.

Are there any side effects or risks?

Fatigue therapies are usually administered by a trained health professional at a rehabilitation clinic or at home. Your therapist will monitor your reactions to the therapy closely. It is important to report to your therapist any changes in your state (e.g. more or less fatigue, sleep quality, independence for daily tasks). Your therapist will adjust the nature, intensity and the duration of therapy according to your ability, endurance and progress.

Is it possible to speak to someone who had a stroke?

Support groups are available in some regions for people who have had a stroke. You can also find stories about people who have had problems similar to yours. Consult your National Stroke Association.

How does my fatigue impact on my recovery?

Fatigue after stroke may make you feel less motivated, more tired, and also may cause you to have trouble concentrating. All these symptoms of fatigue will slow down your recovery. Studies have shown that people who have fatigue after stroke do not get better as quickly as people who do not have fatigue.

I would like to know more about fatigue and stroke?

Understanding how fatigue and stroke happen can reassure you. There are many resources online. Your health care provider can help answer your specific questions.

A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

Please click here to access a video on fatigue posted by Canadian Partnership for stroke recovery.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The current module includes studies examining interventions specific for post-stroke fatigue. Studies were excluded based on the following exclusion criteria: i) fatigue is a secondary outcome and intervention is not fatigue-specific; and ii) the type of intervention is represented by an existing Stroke Engine module. Please see the following Stroke Engine modules for more information on the effects of these intervention on fatigue: Cognitive Rehabilitation, Robotics, Aerobic Exercise, Transcranial Direct Current Stimulation/Transcranial Magnetic Stimulation, Task-Oriented Upper Extremity, Video Games, Balance Training, and Task-Oriented Lower Extremities. The current module includes eight studies: two high quality RCTs, three fair quality RCTs and three non-RCTs design studies. Of these, seven studies included patients with stroke not defined to one specific post-stroke time period (e.g. participants in the subacute or chronic stage of stroke recovery). The following five types of interventions for post-stroke fatigue emerged and are included in the present module: Mindfulness-based stress reduction, Inspiratory muscle training, Group sports, Multimodal intervention (cognitive and physical training), and Fatigue management psychoeducation.

No studies on interventions for post-stroke fatigue were found for patients specifically in the acute and subacute phase of stroke recovery.

Outcomes

Chronic phase - Mindfulness

Anxiety
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on anxiety in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Anxiety was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Anxiety) at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing anxiety in patients with chronic stroke.

Depression
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on depression in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Depression was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Depression) at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing depression in patients with chronic stroke.

Executive function
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on executive functions in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Executive function was measured by the Trail Making Test (TMT: A, B, C, D) and the Wechsler Adult Intelligence Scale-III: Digit Symbol-Coding Test at post-treatment (8 weeks). A significant between-group difference was found on only one measure of executive function (TMT – A) in favour of MBSR treatment vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving executive function in patients with chronic stroke.
Note: Significant between-group differences in TMT-A were also found at baseline, favoring MBSR vs. no treatment. Significant between-group differences in TMT-B and TMT-C scores were found at post-treatment, but differences did not remain significant when adjusted with TMT-A scores.

Mental fatigue
Effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on mental fatigue in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Mental fatigue was measured by the Self-Evaluation Questionnaire for Mental Fatigue at post-treatment (8 weeks). A significant between-group difference was found in favour of MBSR treatment vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is more effective than no treatment in reducing mental fatigue in patients with chronic stroke.

Reading speed
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on reading speed in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Reading speed was measured by a Reading Speed Dyslexia Screening test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving reading speed in patients with chronic stroke.

Verbal fluency
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on verbal fluency in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Verbal fluency was measured by the FAS Verbal Fluency Test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving verbal fluency in patients with chronic stroke.

Working memory
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on working memory in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Working memory was measured by the Wechsler Adult Intelligence Scale-III: Digit Span Test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving working memory in patients with chronic stroke.

Phase not specific to one period - Fatigue management education

Activities of daily living
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. ADLs were measured by the Barthel Index and the modified Rankin Scale at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving activities of daily living in patients with stroke.

Anxiety
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on anxiety in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing anxiety in patients with stroke.

Depression
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) and one non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on anxiety in patients with stroke.

The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Depression was measured by the Hospital Anxiety and Depression Scale (HADS: Depression) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

The non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Depression was measured by the Patient Health Questionnaire (PHQ-9) at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (1 month).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing depression in patients with stroke. Similarly, a pre-post design study found no significant immediate or long-term benefits from a psychoeducation program.

Fatigue
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012), and two non-randomized studies (Wu et al., 2017; Boehm, Muehlberg & Stube, 2015) investigated the effect aof fatigue management education on fatigue in patients with stroke.

The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Fatigue was measured by the Fatigue Severity Scale, a Visual Analogue Scale for Fatigue (Fatigue, Vigor), and the Checklist of Individual Strength at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

A non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (3 months).

A case report (Boehm, Muehlberg & Stube, 2015) allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Fatigue was measured by the Fatigue Impact Scale (FIS: Physical Fatigue, Cognitive Fatigue, Social Fatigue) at post-treatment (5 weeks). Improvements were noted on all measures of fatigue, however no statistical results were provided. This study is not used in the conclusion below.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing fatigue in patients with stroke. A non-randomized also reported no significant improvements in fatigue immediately following a psychoeducation program.

Health-related quality of life
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on health-related quality of life in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Health-related quality of life was measured by the Short Form-36 (SF-36: Physical functioning, Role physical, Role emotional, Energy/Fatigue, Emotional wellbeing, Social functioning, Pain, General Health) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving health-related quality of life in patients with stroke.

Instrumental activities of daily living
Insufficient evidence
5

One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on instrumental activities of daily living (IADLs) in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. IADLs were measured by the Nottingham Extended Activities of Daily Living at post-treatment (6 sessions) and follow-up (1 month, 3 months). No significant improvements were found at any time point.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on instrumental activities of daily living in patients with stroke. However, one pre-post design study found no significant improvements in instrumental activities of daily living following an psychoeducation program.

Occupational performance
Insufficient evidence
5

One case-report (Boehm, Muehlberg & Stube, 2015) investigated the effect of fatigue management education on occupational performance in a patient with stroke. This case-reported allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM: Perceived performance, Satisfaction) at post-treatment (5 weeks). No improvements were noted and no statistical results were provided.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on occupational performance in patients with stroke. However, one case report found no improvement in occupational performance following a fatigue management course.

Stroke outcomes
Insufficient evidence
5

One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on stroke outcomes in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Stroke outcomes were measured by the Stroke Impact Scale (SIS: General recovery, Physical strength, Memory and thinking, Emotion, Communication, Daily activities, Mobility, Hand function, Social activity) at post-treatment (6 sessions) and follow-up (1 month, 3 months). Significant improvements were noted in some stroke outcomes at post-treatment (SIS: Mobility, Social activity), 1-month follow-up (SIS: Mobility, Social activity), and 3-month follow-up (SIS: General recovery, Memory and thinking, Emotion, Mobility, Social activity).

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on stroke outcomes in patients with stroke. However, one pre-post design study found significant improvements in some stroke outcomes following a psychoeducation program.

Phase not specific to one period - Group sports

Depression
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on depression in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Depression was measured by the Korean version of the State Depression Scale at post-treatment (2 weeks). A significant between-group differences was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing depression in patients with stroke.

Fatigue
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on fatigue in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Brief Fatigue Inventory at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing fatigue in patients with stroke.

Functional independence
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on functional independence in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM: Motor, Cognition, Total scores) at post-treatment (2 weeks). Significant between-group differences were found in two measures of functional independence (FIM: Motor, Total scores), favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving functional independence in patients with stroke.

Sleep quality
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on sleep quality in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Sleep quality was measured by the Pittsburgh Sleep Quality Index at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving sleep quality in patients with stroke.

Phase not specific to one period - Inspiratory muscle training

Activities of daily living
Effective
2a

One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. ADLs were measured by the Barthel Index at post-treatment (10 weeks). A significant between-group difference was found, favoring IMT vs. no treatment. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is more effective than no treatment in improving activities of daily living in patients with stroke.

Fatigue
Not effective
1b

One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on fatigue in patients with stroke.

The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (6 weeks). No significant between-group difference was found.

The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (10 weeks). No significant between-group difference was found. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that inspiratory muscle training is not more effective than no treatment in reducing fatigue in patients with stroke.

Perceived exertion
Not effective
2a

One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on perceived exertion in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Perceived exertion was measured by the modified Borg Scale at post-treatment (10 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is not more effective than no treatment in improving perceived exertion in patients with stroke.

Respiratory function
Effective
1b

One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on respiratory function in patients with stroke.

The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Respiratory function (MIP, IME, affected/non-affected DT at rest/contraction, affected/non-affected DT thickness ratio) was measured by the inspiratory muscle training device PowerBreath K5 (2010, HaB International LtD, UK) at post-treatment (6 weeks). Significant between-group differences were found in some measures of respiratory function (MIP, IME, affected DT at contraction, affected DT thickness ratio), favoring IMT vs. no treatment.

The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Respiratory function (FVC, FEV1, ratio FEV1/FVC, MIP, MEP, MMEF, SpO2) was measured by standard spirometer and a finger pulse oximeter at post-treatment (10 weeks). A significant between-group difference was found in one measure of respiratory function (MIP), favoring IMT vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is more effective than no treatment in improving respiratory function in patients with stroke. In addition, one fair quality RCT found a significant between-group difference in one measure of respiratory function, favoring inspiratory muscle training compared to no treatment.
DT: Diaphragm thickness IME: Inspiratory muscle endurance FVC: Forced Vital Capacity FEV1: Forced Expiratory Volume in 1 sec MIP: Maximal inspiratory pressure MEP: Maximal expiratory pressure MMEF: Maximal mid-expiratory flow SpO2: Resting oxyhemoglobin saturation.

Walking endurance
Not effective
1b

One high quality RCT (Cho et al., 2018) investigated the effect of inspiratory muscle training (IMT) on endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Walking endurance was measured by the 6-Minute Walk Test at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is not more effective than no treatment in improving walking endurance in patients with stroke.

Phase not specific to one period - Multimodal intervention

Fatigue
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Fatigue was measured by the Checklist Individual Strength (CIS: Fatigue) and the Fatigue Self-Observation List at post-treatment (3 months) and follow-up (6 months). There were no significant between-group differences on either measure at either time point.
Note: The authors noted a significant clinically relevant improvement in CIS: Fatigue scores at follow-up, for the cognitive therapy group with graded activity training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing fatigue in patients with stroke.

Health-related quality of life
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. HRQoL was measured by the Stroke-Adapted Sickness Impact Profile at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving health-related quality of life in patients with stroke.

Mood and affect
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on mood and affect in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Mood and affect were measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety, Depression) at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving mood and affect in patients with stroke.

Pain
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on pain in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Pain was measured by the Pain Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing pain in patients with stroke.

Sleep quality
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on sleep quality in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Sleep quality was measured by the Sleep Quality Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving sleep quality in patients with stroke.

Walking endurance
Effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on walking endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (3 months) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring cognitive therapy with graded activity vs. cognitive therapy alone. This between-group difference remained significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is more effective than a comparison intervention (cognitive therapy alone) in improving walking endurance in patients with stroke.

References

Acciarresi, M., Bogousslavsky, J., & Paciaroni. M. (2014). Post-stroke fatigue: epidemiology, clinical characteristics and treatment. European Neurology, 72, 255-61

Boehm, N., Muehlberg, H., & Stube, J.E. (2015). Managing poststroke fatigue using telehealth: a case report. American Journal of Occupational Therapy69(6), 6906350020p1-6906350020p7.
https://ajot.aota.org/article.aspx?articleid=2465091

Carlsson, G.E., Möller, A., & Blomstrand, C. (2003). Consequences of mild stroke in persons. Cerebrovascular Diseases16(4), 383-388.

Chen PC, Liaw MY, Wang LY, Tsai YC, Hsin YJ, Chen YC, Chen SM, Lin MC. (2016). Inspiratory muscle training in stroke patients with congestive heart failure: A CONSORT-compliant prospective randomized single-blind controlled trial. Medicine (Baltimore). Sep;95(37):e4856. doi: 10.1097/MD.0000000000004856.
https://www.ncbi.nlm.nih.gov/pubmed/27631248

Cho JE, Lee HJ, Kim MK, Lee WH. (2018). The improvement in respiratory function by inspiratory muscle training is due to structural muscle changes in patients with stroke: a randomized controlled pilot trial.Top Stroke Rehabil. Jan;25(1):37-43. doi: 10.1080/10749357.2017.1383681.
https://www.ncbi.nlm.nih.gov/pubmed/29061084

Clarke, A., Barker-Collo, S.L., & Feigin, V.L. (2012). Poststroke fatigue: does group education make a difference? A randomized pilot trial. Topics in Stroke Rehabilitation19(1), 32-39.
https://www.tandfonline.com/doi/abs/10.1310/tsr1901-32

Cumming, T.B., Packer, M., Kramer, S.F., & English, C. (2016). The prevalence of fatigue after stroke: a systematic review and meta-analysisInternational Journal of Stroke, 11, 968-77.

Cumming, T.B., Yeo, A.B., Marquez, J., Churilov, L., Annoni, J.M., Badaru, U., … & Mills, R. (2018). Investigating post-stroke fatigue: An individual participant data meta-analysisJournal of Psychosomatic Research113, 107-112.

Glader, E.L., Stegmayr, B., & Asplund, K. (2002). Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke33(5), 1327-1333.

Johansson, B., Bjuhr, H., & Rönnbäck, L. (2012). Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury. Brain Injury26(13-14), 1621-1628.
https://www.tandfonline.com/doi/abs/10.3109/02699052.2012.700082

Kim, I. (2012). Effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients. Clinical Nursing Research21(4), 390-405.
https://journals.sagepub.com/doi/abs/10.1177/1054773812439204

Paul, L., Wyke, S., Brewster, S., Sattar, N., Gill, J. M., Alexander, G., … & Dybus, A. (2016). Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study. Topics in Stroke Rehabilitation23(3), 170-177.
https://www.tandfonline.com/doi/abs/10.1080/10749357.2015.1122266

Schepers, V.P., Visser-Meily, A.M., Ketelaar, M., & Lindeman, E. (2006). Poststroke fatigue: course and its relation to personal and stroke-related factors. Archives of Physical Medicine and Rehabilitation87(2), 184-188.

Staub, F. & Bogousslavsky, J. (2001). Fatigue after stroke: a major but neglected issue. Cerebrovascular Diseases12(2), 75-81.

Terrill, A.L., Schwartz, J.K., & Belagaje, S.R. (2018). Best Practices for The Interdisciplinary Rehabilitation Team: A Review of Mental Health Issues in Mild Stroke Survivors. Stroke Research and Treatment, Volume 2018, Article ID 6187328.

Wu, S., Chalder, T., Anderson, K.E., Gillespie, D., Macleod, M.R., & Mead, G.E. (2017). Development of a psychological intervention for fatigue after stroke. PloS One12(8), e0183286.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183286

Zedlitz, A.M., Rietveld, T.C., Geurts, A.C., & Fasotti, L. (2012). Cognitive and graded activity training can alleviate persistent fatigue after stroke: a randomized, controlled trial. Stroke, STROKEAHA-111.
https://repository.ubn.ru.nl//bitstream/handle/2066/102380/M_346855.pdf?sequence=1

Music Therapy

Evidence Reviewed as of before: 19-07-2017
Author(s)*: Tatiana Ogourtsova, PhD Candidate MSc BSc OT; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Music interventions are used to optimize an individual’s emotional well-being, physical health, social functioning, communication abilities, and cognitive skills. This module reviews studies that incorporate music as the primary type of intervention.

Patient/Family Information

Authors*: Erica Kader; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Nicol Korner-Bitensky, PhD OT

What is music therapy?

Music therapy is a specific form of rehabilitation that is typically facilitated by an accredited music therapist and uses music in a variety of ways to help achieve therapeutic goals. Music therapy has been found to be helpful for people who have had a stroke. Since music is emotionally and intellectually stimulating, this form of therapy can help to maintain or improve one’s physical and mental health, quality of life, and well-being.

Are there different kinds of music therapy?

Music therapy can be provided in different forms, depending on your needs and preferences. Various ways of conducting music therapy and its benefits include:

  • Active listening – develops attention, memory, and awareness to your environment.
  • Composing/songwriting – can be a way of sharing your feelings and being able to express yourself.
  • Improvising movements to music – a creative, non-verbal way of expressing feelings. Since improvisation does not require any previous musical training anyone can participate.
  • Rhythmic movements and dancing – improves movement, speed, balance, breathing, stamina, relaxation of muscles, and walking.
  • Playing instruments – increases coordination, balance, and strength. As an example, hitting a tambourine with a stick is a good exercise to improve your hand-eye coordination and develop strength in your arms and hands. This is a great activity whether or not you have previous experience playing instruments.
  • Singing – improves communication, speech, language skills, articulation, and breathing control. Singing is particularly useful after a stroke for those who are unable to speak, because sometimes even though speech is affected, the individual is still able to sing. This happens because the speech center located in the brain is in a different location than the brain area used for singing. So, someone may have damage to the brain area responsible for speech, but no damage to the area responsible for singing.
With permission of the Music Therapy Association of British Columbia

Is music therapy offered individually or in a group?

Music therapy can be offered either way, so it is your choice. You and your music therapist can plan your music therapy sessions together. Benefits to participating in a group includes improving communication and social skills, making new friends, and the opportunity to share feelings and experiences. Playing instruments in a group can help develop cooperation and attention, as well as improve self-esteem and well-being. Composing and songwriting is another activity that works well in a group, as it allows you to communicate and work along with others. If you are not comfortable working in a group, music therapy sessions can also be offered on an individual basis. Individual sessions may lead to group sessions later on in the rehabilitation process, or the treatment plan may involve a combination of both. For people who are restricted to bed, music therapy can even be offered at their bedside with portable instruments.

Why use music therapy after a stroke?

Music therapy has the ability to help in the rehabilitation of individuals who have had a stroke. The research on the effects of this intervention is still quite new. There is some limited evidence suggesting that music therapy can help improve the movement of the arms, walking, pain perception, mood, and behaviour after stroke.

Courtesy of the Institute for Music and Neurologic Function

Do music-based treatments work in post-stroke rehabilitation?

Researchers have studied how different music-based treatments can help patients with stroke:

In individuals with ACUTE stroke (up to 1 month after stroke), studies found that:

  • Listening to music is MORE helpful than comparison treatment(s) in improving attention, memory, mood and affect. It is AS helpful as comparison treatment(s) in improving executive functions (cognitive processes that assist in managing oneself and one’s resources in order to achieve a goal), language, music cognition, quality of life, and the ability to identify visual and spatial relationships among objects.
  • Music-movement therapy is MORE helpful than comparison treatment(s) in improving mood and affect, and range of motion. It is AS helpful as comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), and muscle strength.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving walking ability.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), studies found that:

  • Music training is MORE helpful than a comparison treatment in improving hand and arm function.

In individuals with CHRONIC stroke (more than 6 months after stroke), studies found that:

  • Music therapy + occupational therapy is MORE helpful than comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), quality of life, sensation, and arm function. It is AS helpful as comparison treatment(s) in improving consequences of stroke, and arm movement quality.
  • Melodic intonation therapy is AS helpful as a comparison treatment in improving language.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, behavior, walking ability, grip strength, interpersonal relationships, quality of life, legs range of movement, consequences of stroke, and mood and affect. They are AS helpful as comparison treatment(s) in improving cognitive functions (e.g. attention), dexterity, language, musical behavior, occupational performance, arm function, memory, and walking endurance.

In individuals with stroke (acute, subacute and/or chronic), studies found that:

  • Melodic intonation therapy is MORE helpful than a comparison treatment in improving language.
  • Music performance is AS helpful as comparison treatment(s) in improving dexterity and arm range of motion and function.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, and walking ability. They are AS helpful as comparison treatment(s) in improving dexterity, sensation, strength, stroke consequences, arm function and activity.

Who provides the treatment?

Many hospitals and rehabilitation centers have music therapy programs that are conducted by accredited music therapists. The music therapist will meet with you to assess your needs and discuss preferences, so that he or she can design a program specific to your needs. In some centers it may be a recreational therapist or leisure therapist who provides music therapy. Ask your health professional or family members to help you find out more about the music therapy services offered in your hospital, rehabilitation center or community.

Are there any side effects or risks?

You do not face any risks when participating in music therapy after a stroke, as long as activities are practiced in a manner that fits your abilities. Consult your physician or rehabilitation healthcare professional for the best advice on how to participate safely. This is especially important if you are going to incorporate dancing or rhythmic movements into your music sessions and have some balance difficulties. *Family members/friends: it is important to help the person who has had a stroke seek out new activities such as music therapy that may be both pleasant and therapeutic.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

This module reviews 24 studies that use music as a primary means of rehabilitation; of these, 12 are high quality RCTs, seven are fair quality RCTs, one is a poor quality RCT and four are non-randomized studies.

This module reviews the following types of music-based interventions:

Listening to music: participants listening to music.

Music therapy + occupational therapy: participants playing instruments (e.g. drums, bells, shakers, mallets, chimes, piano, harp) with the affected upper limb to encourage proximal and distal upper limb movements, with attention to positioning and movement quality.

Melodic intonation therapy: participants singing phrases and tap to the rhythm of the phrases; this intervention has been shown to improve outcomes related to language/aphasia.

Music-movement therapy: participants performing movements of lower and upper extremities while listening to music.

Music performance: participants playing acoustic musical instruments and/or iPads with touchscreen musical instruments as part of fine/distal exercise.

Music training: participants are taught to play a musical instrument.

Rhythmic music interventions: participants performing matching upper and/or lower extremity movements or gait patters to musical rhythm.

Results Table

View results table

Outcomes

Acute phase - Listening to music

Attention
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on attention in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of attention were taken at 3 and 6 months post-stroke, and outcomes included: (1) attention, measured by the CogniSpeed reaction time software; (2) focused attention, measured by the mental subtraction and Stroop subtests (number correct and reaction time); and (3) sustained attention, measured by the vigilance (number correct, reaction time) and simple reaction time subtests. Significant between-group differences in focused attention were found at 3 months post-stroke, favoring the music group vs. the control group. Significant between-group differences in focused attention were found at 6 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. There were no significant between-group differences in other measures of attention at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving focused attention in patients with acute stroke. However, no between-group differences were found on measures of attention or sustained attention.

Auditory sensory memory
Not effective
1b

One high quality RCT (Sarkamo et al., 2010) investigated the effect of music interventions on auditory sensory memory in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Auditory sensory memory was evaluated by the magnetically-measured mismatch negativity (MMNm) responses to change in sound frequency and duration from baseline to 3 and 6 months post-stroke. There were no significant differences between groups at 3 months post-stroke. At 6 months post-stroke, there were significant between-group differences in auditory sensory memory (frequency MMNm only), favoring the music group vs. the control group.
Note: Comparison of the audio book group vs. the control group revealed significant differences favoring the audio book group in frequency MMNm (left and right lesions) and duration MMNm (right lesions only) at 6 months post-stroke.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving auditory sensory memory among patients with acute stroke in the short term.
Note:
However, this high quality RCT showed that patients who listened to music demonstrated significantly better auditory sensory memory several months following treatment than patients who received conventional rehabilitation alone.

Executive function
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on executive function in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Executive function was measured by the Frontal Assessment Battery at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving executive function in patients with acute stroke.

Language
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on language in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Language was measured by the Finnish version of the Boston Diagnostic Aphasia Examination (word repetition, sentencing repetition, reading subtests), the CERAD battery (verbal fluency, naming subtests) and the Token Test at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving language in patients with acute stroke.

Memory
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on memory in patients with acute stroke. This high quality RCT randomized patients to a music group that listened to music for a minimum 1 hour/day, a language group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of memory were taken at 3 and 6 months post-stroke and outcomes included: (1) verbal memory, measured by the Rivermead Behavioral Memory Test (story recall subtests) and an auditory list learning task; and (2) short-term working memory, measured by the Wechsler Memory Scale – Revised (digit span subtest) and a memory interference task. Significant between-group differences in verbal memory were found at 3 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. Similarly, significant between-group differences in verbal memory were found at 6 months post-stroke, favoring the music group vs. the audio book group. There were no significant between-group differences in short-term working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving verbal memory in patients with acute stroke. However, no between-group differences were found on measures of short-term working memory.

Mood
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on mood in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Mood was measured by a shortened Finnish Version of the Profile of Mood States at 3 and 6 months post-stroke. Significant between-group differences in mood (depression score only) were found at 3 months post-stroke favoring the music group vs. the control group.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving mood in patients with acute stroke.

Music cognition
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on music cognition in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Music cognition was measured by the Montreal Battery of Evaluation of Amusia (scale and rhythm subtests) at 3 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving music cognition in patients with acute stroke.

Quality of life
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on quality of life in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Quality of life was measured by the Stroke and Aphasia Quality of Life Scale – 39 (self-rated, proxy rated) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (audio therapy, no training) in improving quality of life in patients with acute stroke.

Visuospatial skills
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on visuospatial skills in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Visuospatial skills were measured by the Clock Drawing Test, Figure Copying Test, Benton Visual Retention Test (short version), and Balloons Test (subtest B) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving visuospatial skills in patients with acute stroke.

Acute phase - Music-movement therapy

Behavioral outcomes
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on mood and affect in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Behavioral outcomes were assessed according to: 1) mood measured by the Korean version of the Profile of Mood States Brief Instrument; and 2) depression, measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (8 weeks). Significant between-group differences were found for mood favoring music-movement therapy vs. no training.  

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving behavioral outcomes (mood) in patients with acute stroke.

Functional independence
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on functional independence in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Functional independence was measured by the Korean modified Barthel Index at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving functional independence in patients with acute stroke.

Muscle strength
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on muscle strength in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Muscle strength of the affected upper and lower extremities was measured by the Medical Research Council Scale at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving muscle strength in patients with acute stroke.

Range of motion
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on range of motion (ROM) in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. ROM of the affected side (shoulder/elbow/wrist flexion, hip/knee flexion) was measured by goniometer at post-treatment (8 weeks). Significant between-group differences in ROM were found (shoulder/elbow flexion, hip flexion), favoring music-movement therapy vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving range of motion of the proximal joints of patients with acute stroke.

Acute phase - Rhythmic music interventions

Gait parameters
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Subacute phase - Music training

Dexterity
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Upper extremity motor function
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on upper extremity motor function in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone.  Upper extremity motor function was measured by the Action Research Arm Test, Arm Paresis Score, and computerized hand/fingers movement analysis (velocity and frequency profile) at post-treatment (3 weeks). Significant between-group differences were found on all measures of upper extremity motor function, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Chronic phase - Melodic intonation therapy

Language
Not effective
1b

One high quality RCT (van Der Meulen et al., 2016), investigated the effect of music interventions on language in patients with chronic stroke. This high quality cross-over design RCT randomized patients to receive melodic intonation therapy (MIT) or no treatment. Language was measured by the Sabadel story retell task, Amsterdam-Nijmegen Everyday Language Test, Aachen Aphasia Test (naming, repetition, auditory comprehension), and MIT task (trained/untrained items) at post-treatment (6 weeks) and at follow-up (12 weeks). Significant between-group differences were found on only one measure of language (MIT task – trained items) at post-treatment favoring MIT vs. no treatment. These differences were not maintained at follow-up.
Note: When the control group crossed-over to receive the MIT treatment, no significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that melodic intonation therapy is not more effective than no treatment in improving language in patients with chronic stroke.

Chronic phase - Music therapy and occupational therapy

Functional independence
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on functional independence in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Functional independence was measured by the Modified Rankin Scale at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving functional independence in patients with chronic stroke.

Quality of life
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on quality of life in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Quality of life was measured by the World Health Organization Well-Being Index at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving quality of life in patients with chronic stroke.

Sensation
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on sensation in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Sensation was measured by the Two-Point Discrimination Test at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving sensation in patients with chronic stroke.

Stroke outcomes
Not effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on stroke outcomes in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Stroke outcomes were measured by the Stroke Impact Scale (SIS activities of daily living, participation subscales) at baseline, post-treatment (6 weeks) and follow-up (1 year). There were no significant changes in stroke outcomes from baseline to post-treatment. There was a significant improvement on one measure (SIS – activities of daily living) from post-treatment to follow-up.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is not effective in improving stroke outcomes in patients with chronic stroke in the short term.
Note
: However, the quasi-experimental design study showed significant improvements in one measure of stroke outcomes (activities of daily living) in the long term.

Upper extremity kinematics
Not effective
2b

One quasi-experimental design studies (Raghavan et al., 2016) investigated the effect of music interventions on upper extremity kinematics in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper-limb training. Kinematic analysis of wrist flexion/extension was performed at baseline and at post-treatment (6 weeks). No significant changes were found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is not effective in improving upper extremity kinematics in patients with chronic stroke.

Upper extremity motor function
Effective
2b

One quasi-experimental design studies (Raghavan et al., 2016) investigated the effect of music interventions on upper extremity motor function in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper-limb training. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity subscale at baseline, post-treatment (6 weeks) and 1-year follow-up. Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving upper extremity motor function in patients with chronic stroke.

Chronic phase - Rhythmic music interventions

Balance
Effective
1a

Two high quality RCTs (Cha et al., 2014; Bunketorp-Kall et al., 2017) investigated the effect of music interventions on balance in patients with chronic stroke.

The first high quality RCT (Cha et al., 2014) randomized patients to receive rhythmic auditory stimulation (RAS) gait training or time-matched standard gait training. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks). Significant between-group differences were found, favoring RAS gait training vs. time-matched standard gait training.

The second high quality RCTs (Bunketorp-Kall et al., 2017) randomized patients to receive rhythm-and-music therapy (listening to music while performing rhythmic movements of the hands and feet), horse-riding therapy or no treatment. Balance was measured by the BBS and the Backstrand, Dahlberg and Liljenas Balance Scale (BDL-BS) at post-treatment (12 weeks) and follow-up (6 months). Significant between-group differences (BDL-BS only) were found at post-treatment and follow-up, favoring rhythm-and-music therapy vs. no treatment. There were no significant differences between rhythm-and-music therapy and horse-riding therapy at either time point on any of the measures.
Note: There was also a significant between-group difference (BBS, BDL-BS) at post-treatment, favoring horse-riding therapy vs. no treatment. These differences did not remain significant at follow-up.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that rhythmic music interventions are more effective than comparison interventions (time-matched standard gait training, no treatment) in improving balance in patients with chronic stroke.

Behavior
Effective
2b

One fair quality RCT (Raglio et al., 2016) and one quasi-experimental design study (Purdie et al., 1997) investigated the effect of music interventions on behavior in patients with chronic stroke.

The fair quality RCT (Raglio et al., 2016) randomized patients to receive music therapy (using rhythmic melodic instruments and singing) + speech language therapy or speech language therapy alone. Behavior was measured by the Big Five Observer (energy/extroversion, friendship, diligence, emotional stability, open mindedness) at post-treatment (15 weeks). Neither group demonstrated significant changes in behaviour at post-treatment.
Note: This study did not report between-group analyses so is not used to determine the level of evidence in the conclusion below.

The quasi-experimental design study (Purdie et al., 1997) randomized patients to receive music therapy (using percussion/synthesizers and singing) or no music therapy. Behavior was measured by the Behavior Rating Scale (BRS) at post-treatment (12 weeks). Significant between-group differences were found (BRS emotional stability, spontaneous interaction subscales), favoring music therapy vs. no music therapy.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that rhythmic music intervention is more effective than no music therapy in improving some aspects of behavior in patients with chronic stroke.
Note
: However, one fair quality RCT reported no significant change in behavior following rhythmic music therapy + speech language therapy.

Cognitive function
Not effective
1b

One high quality RCT (Bunketorp-Kall et al., 2017) investigated the effect of music interventions on cognitive function in patients with chronic stroke. This high quality RCT randomized patients to receive rhythm-and-music therapy (listening to music while performing rhythmic movements of the hands and feet), horse-riding therapy or no treatment. Cognitive function was measured by the Barrow Neurological Institute Screen for Higher Cerebral Functions at post-treatment (12 weeks) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that rhythmic music intervention is not more effective than comparison interventions (horse-riding therapy, no treatment) in improving cognitive function in patients with chronic stroke.

Dexterity
Not effective
2b

Two quasi-experimental design studies (Hill et al., 2011; Villeneuve et al., 2014) investigated the effect of music interventions on dexterity in patients with chronic stroke.

The first quasi-experimental design study (Hill et al., 2011) assigned patients to receive rhythm and timing training (interactive metronome training) + occupational therapy or occupational therapy alone. Dexterity was measured by the Box and Block Test at post-treatment (10 weeks). No significant between-group differences were found

The second quasi-experimental AABA design study (Villeneuve et al., 2014) assigned patients to receive music-supported therapy (using piano training). Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks) and follow-up (6 weeks). Significant improvements in both measures of dexterity were found at post-treatment. No significant changes in scores were observed from post-treatment to follow-up.
Note: This study did not report between-group analyses so is not used to determine level of evidence in the conclusion below.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that rhythmic music intervention is not more effective than a comparison intervention (occupational therapy alone) in improving dexterity in patients with chronic stroke.
Note
: One quasi-experimental design study found improvements in dexterity immediately following music-supported therapy using piano training.

Gait parameters
Effective
1b

One high quality RCT (Cha et al., 2014) investigated the effect of music interventions on gait parameters in patients with chronic stroke. This high quality RCT randomized patients to receive rhythmic auditory stimulation (RAS) gait training or time-matched standard gait training. Gait parameters (gait velocity, cadence, stride length of the affected/less-affected legs, double stance period of the affected/less-affected legs) were measured by the GAITRite system at post-treatment (6 weeks). Significant between-group differences were found for all gait parameters of the affected leg and most gait parameters of the less affected leg (excluding stride length, double stance period), favoring RAS gait training vs. time-matched standard gait training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT