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Does constraint-induced aphasia therapy or multimodal aphasia therapy lead to better outcomes for people with chronic post-stroke aphasia? A review of latest evidence and rationale for the COMPARE clinical trial

Background: Human communication is essentially multimodal however verbal approaches and techniques have traditionally dominated behavioural aphasia therapies. These verbal techniques are the hallmark of constraint-induced aphasia interventions (Rose, 2013). Recent evidence reveals both the considerable gesture abilities of people with aphasia and the complex, interacting neural networks that underpin verbal and nonverbal communication (Rose, 2013). It is possible that such nonverbal abilities may be positively harnessed in aphasia therapy that is aimed at improving spoken communication, through explicit cueing of nonverbal elements to facilitate word retrieval and/ or support language re-learning. The principles of neuroplasticity, including “use it or lose it” (and associated concepts of learned non-use), specificity, salience, transference, and interference, are largely derived from animal motor system models. These principles require careful interpretation when applied to rehabilitation of human language and cognition. Currently, clinicians have little guidance about whether to focus on multimodal cueing in their aphasia therapies or to restrict cueing, activity, and practice to the verbal modality consistent with constraint approaches. Aim: We aimed to investigate the comparative evidence for constraint and multimodal aphasia therapies for changes in language, communication, quality of life, and carer burden outcomes in people with post-stroke aphasia. Methods and Procedures: We systematically reviewed the literature on constraint and multimodal aphasia therapies (Pierce, Menahemi-Falkov, O’Halloran, Togher, & Rose, 2017). Databases were searched in September 2015 without date restriction. We included randomised controlled trials (RCT), parallel group, and single subject design studies. Studies included in two recent related systematic reviews (Brady, Kelly, Godwin, Enderby, & Campbell, 2016; Zhang et al., 2017) were added to the original yield. Studies meeting inclusion criteria were rated for quality on the PEDro-P scale for RCTs andnon-randomised trials, and the RoBiNT scale for single-subject experimental designs. Effect sizes were calculated and compared for studies exceeding quality thresholds (≥5 PEDro-P; ≥12 RoBiNT). Outcomes and results: From the yield of 1251 non-duplicate citations, 62 articles met inclusion/exclusion criteria for quality review and synthesis. Of these 16 multimodal and