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Intensive speech therapy after stroke

This month we publish an important paper evaluating intensive aphasia therapy after acute stroke. Physiotherapy, speech and language therapy, and occupational therapy are important components of stroke rehabilitation, but despite their widespread use, there is limited data evaluating which components of each are most effective and how intensive therapy needs to be to gain maximal benefit. In the longer term, intensive therapy interventions have been shown to improve outcome; for example in upper limb neurorehabilitation. However, whether ‘‘more intensive therapy is better’’ when commenced in the early phases after stroke, during which there is a rapid spontaneous recovery, is uncertain. The recent important AVERT trial in over 2000 acute stroke patients found frequent higher dose early mobilization, which was associated with a higher dose of therapy, was unexpectedly associated with a reduced odds of a favourable outcome at three months. This questions the hypothesis that more intensive therapy is better at early timepoints after stroke. The Very Early Rehabilitation for SpEech (VERSE) collaborators applied a similar approach to determine whether early intensive aphasia therapy resulted in improved recovery compared with usual care, and they describe their results in this issue. Two hundred and forty-six aphasic acute stroke patients were randomized to either usual care, usual care-þ, or VERSE treatment which was an impairment-based therapy program developed by an aphasia expert advisory committee. The latter two high intensity groups received a total mean time of 22.7 h of aphasia therapy (average of 5 h per week), compared with a mean of 9.5 h over 28 days in the usual care group. Despite this difference in care received, there was no difference in the primary outcome, with communication recovery seen in 50.3% of the high intensity group and 52% in the usual care group. The authors point out that they are not testing whether patients should receive any speech therapy which is an important component of stroke care, but that their results demonstrate that additional intensive speech therapy input is not associated with an improved outcome when delivered during the acute phase after stroke. Studies such as AVERT and VERSE are vital if we are to optimize delivery of stroke rehabilitation services in a therapeutically effective and cost-effective manner. They demonstrate how definitive information on the benefits of treatment can only be obtained by randomized controlled trials, and that such trials are possible in the rehabilitation arena. Sometimes, these trials result in unexpected results. For example, an early pilot study had suggested that VERSE therapy was associated with improved outcome. The VERSE investigators are to be congratulated on an important study. In this issue, we also cover rehabilitation of stroke with a review on apathy after stroke by Jonathan Tay et al. This can be a particularly difficult symptom to treat and is troubling not only for the patient, but often even more for the partner. The review describes how to define the condition, exciting new insights into what causes apathy following stroke and how disruption of complex networks underlying reward seeking behavior may play a role, and treatment approaches. Sadly, there are few effective evaluated treatments. Perhaps another area for the VERSE investigators to tackle? Our second review moves to the other end of the stroke spectrum, hyperacute intervention. One of the most important historical concepts developed in acute stroke is that of the ischaemic penumbra. Seminal early work by Symon and others demonstrated that in some individuals penumbral tissue remained many hours after stroke onset. Progress followed with MRI and CT techniques being developed to identify potentially salvageable tissue. More recently, these have been implemented in both thrombectomy and thrombolysis trials and have allowed identification of patients at delayed timepoints post-stroke who will still benefit from reperfusion therapy. The review by Ermine et al. provide an interesting insight into how these ideas have developed and what impact they have had on patient outcome. It is a very nice illustration of how long it may take to translate important basic science insights into improved clinical care, but also how important these early insights were.