Interventions for dysarthria due to stroke and other adult- acquired, non-progressive brain injury

64 Pages·2017·0.78 MB·English

CochraneDatabaseofSystematicReviews
Interventions for dysarthria due to stroke and other adult-
acquired, non-progressive brain injury (Review)
MitchellC,BowenA,TysonS,ButterfintZ,ConroyP
MitchellC,BowenA,TysonS,ButterfintZ,ConroyP.
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury.
CochraneDatabaseofSystematicReviews2017,Issue1.Art.No.:CD002088.
DOI:10.1002/14651858.CD002088.pub3.
www.cochranelibrary.com
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review)
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis1.1.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboorno
intervention:persistingeffects,Outcome1Primaryoutcomeofdysarthriainterventionversusanycontrol:persisting
effects,activitylevel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Analysis1.2.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboor
nointervention:persistingeffects,Outcome2Secondaryoutcomeofdysarthriainterventionversusanycontrol:
persistingeffects,impairmentlevel. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Analysis1.3.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboor
nointervention:persistingeffects,Outcome3Secondaryoutcomeofdysarthriainterventionversusanycontrol:
persistingeffects,participationlevel. . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis1.4.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboorno
intervention:persistingeffects,Outcome4Primaryoutcomeofdysarthriainterventionversusanycontrol:persisting
effects,activitylevel:adequateallocationconcealment/adequateblinding. . . . . . . . . . . . . . 45
Analysis1.5.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboorno
intervention:persistingeffects,Outcome5Secondaryoutcomeofdysarthriainterventionversusattentioncontrol,
placeboornointervention:persistingeffects,activitylevel. . . . . . . . . . . . . . . . . . . 46
Analysis1.6.Comparison1Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboorno
intervention:persistingeffects,Outcome6Secondaryoutcomeofdysarthriainterventionversusanycontrolforstroke
subgroup:persistingeffects,activitylevel. . . . . . . . . . . . . . . . . . . . . . . . . 46
Analysis2.1.Comparison2DysarthriaInterventioncomparedwithanotherintervention,attentioncontrol,placeboor
nointervention:immediateeffects,Outcome1Secondayoutcomeofdysarthriainterventionversusanycontrol:
immediateeffects,activitylevel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis2.2.Comparison2DysarthriaInterventioncomparedwithanotherintervention,attentioncontrol,placeboor
nointervention:immediateeffects,Outcome2Secondaryoutcomeofdysarthriainterventionversusanycontrol:
immediateeffects,impairmentlevel. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Analysis2.3.Comparison2DysarthriaInterventioncomparedwithanotherintervention,attentioncontrol,placeboor
nointervention:immediateeffects,Outcome3Secondaryoutcomeofdysarthriainterventionversusanycontrol:
immediateeffects,participationlevel. . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis3.1.Comparison3DysarthriainterventionAversusdysarthriainterventionB:persistingandimmediateeffects,
Outcome1SecondaryoutcomeofdysarthriainterventionAversusdysarthriainterventionB:persistingeffects,
activitylevel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis3.2.Comparison3DysarthriainterventionAversusdysarthriainterventionB:persistingandimmediateeffects,
Outcome2SecondaryoutcomeofdysarthriainterventionAversusdysarthriainterventionB:persistingeffects,
participationlevel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) i
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 60
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) ii
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Interventions for dysarthria due to stroke and other adult-
acquired, non-progressive brain injury
ClaireMitchell1,2,AudreyBowen1,SarahTyson3,ZoeButterfint4,PaulConroy1
1Division ofNeuroscienceandExperimentalPsychology, UniversityofManchesterMAHSC,Manchester,UK.2ManchesterRoyal
Infirmary,CentralManchesterUniversityHospitalsNHSFoundationTrust,MAHSC,Manchester,UK.3DivisionofNursing,Mid-
wifery&SocialWork,UniversityofManchester,Manchester,UK.4SchoolofHealthSciences,UniversityofEastAnglia,Norwich,
UK
Contactaddress:ClaireMitchell,DivisionofNeuroscienceandExperimentalPsychology,UniversityofManchesterMAHSC,Ellen
WilkinsonBuilding,Manchester,[email protected].
Editorialgroup:CochraneStrokeGroup.
Publicationstatusanddate:Newsearchforstudiesandcontentupdated(conclusionschanged),publishedinIssue1,2017.
Reviewcontentassessedasup-to-date: 6May2016.
Citation: Mitchell C, Bowen A, Tyson S, Butterfint Z, Conroy P. Interventions for dysarthria due to stroke and other adult-
acquired, non-progressive brain injury. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD002088. DOI:
10.1002/14651858.CD002088.pub3.
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Dysarthriaisanacquiredspeechdisorderfollowingneurologicalinjurythatreducesintelligibilityofspeechduetoweak,imprecise,slow
and/orunco-ordinated musclecontrol.Theimpactofdysarthriagoesbeyondcommunication andaffectspsychosocialfunctioning.
Thisisanupdateofareviewpreviouslypublishedin2005.Thescopehasbeenbroadenedtoincludeadditionalinterventions,andthe
titleamendedaccordingly.
Objectives
To assess theeffectsof interventions toimprove dysarthricspeechfollowing stroke and othernon-progressive adult-acquired brain
injurysuchastrauma,infection,tumourandsurgery.
Searchmethods
We searchedthe Cochrane Stroke Group Trials Register (May 2016), CENTRAL (Cochrane Library 2016, Issue 4), MEDLINE,
Embase,andCINAHLon6May2016.WealsosearchedLinguisticsandLanguageBehavioralAbstracts(LLBA)(1976toNovember
2016)andPsycINFO(1800toSeptember2016).Toidentifyfurtherpublished,unpublishedandongoingtrials,wesearchedmajor
trialsregisters:WHOICTRP,theISRCTNregistry,andClinicalTrials.gov.Wealsohandsearchedthereferencelistsofrelevantarticles
andcontactedacademicinstitutionsandotherresearchersregardingotherpublished,unpublishedorongoingtrials.Wedidnotimpose
anylanguagerestrictions.
Selectioncriteria
Weselectedrandomisedcontrolledtrials(RCTs)comparingdysarthriainterventionswith1)nointervention,2)anotherintervention
for dysarthria (this intervention may differ in methodology, timing of delivery, duration, frequency or theory), or 3) an attention
control.
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 1
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Datacollectionandanalysis
Threereviewauthorsselectedtrialsforinclusion,extracteddata,andassessedriskofbias.Weattemptedtocontactstudyauthorsfor
clarificationandmissingdataasrequired.Wecalculatedstandardisedmeandifference(SMD)and95%confidenceinterval(CI),using
arandom-effectsmodel,andperformedsensitivityanalysestoassesstheinfluenceofmethodologicalquality.Weplannedtoconduct
subgroupanalysesforunderlyingclinicalconditions.
Mainresults
Weincludedfivesmalltrialsthatrandomisedatotalof234participants.Twostudieswereassessedaslowriskofbias;noneoftheincluded
studieswereadequately powered.Two studies usedanattentioncontrol andthreestudiescomparedtoanalternativeintervention,
whichinallcaseswasoneinterventionversususualcareintervention.Thesearcheswecarriedoutdidnotfindanytrialscomparing
aninterventionwithnointervention.Thesearchesdidnotfindanytrialsofaninterventionthatcomparedvariationsintiming,dose,
orintensityoftreatmentusingthesameintervention.Fourstudiesincludedonlypeoplewithstroke;oneincludedmostlypeoplewith
stroke,butalsothosewithbraininjury.Threestudiesdeliveredinterventionsinthefirstfewmonthsafterstroke;tworecruitedpeople
with chronic dysarthria. Three studies evaluated behavioural interventions, one investigated acupuncture and another transcranial
magneticstimulation.Onestudyincludedpeoplewithdysarthriawithinabroadertrialofpeoplewithimpairedcommunication.
Our primary analysis of apersisting (threetonine months post-intervention) effectat theactivity levelof measurement found no
evidenceinfavourofdysarthriainterventioncomparedwithanycontrol(SMD0.18,95%CI-0.18to0.55;3trials,116participants,
GRADE: low quality, I² = 0%). Findings fromsensitivity analysis of studies at low risk of bias were similar, with a slightly wider
confidenceintervalandlowheterogeneity(SMD0.21,95%CI-0.30to0.73,I²=32%;2trials,92participants,GRADE:lowquality).
Subgroupanalysisresultsforstrokeweresimilartotheprimaryanalysisbecausefewnon-strokeparticipantshadbeenrecruitedtotrials
(SMD0.16,95%CI-0.23to0.54,I²=0%;3trials,106participants,GRADE:lowquality).
Similarresultsemergedfrommostofthesecondaryanalyses.Therewasnoevidenceofapersistingeffectattheimpairment(SMD0.07,
95%CI-0.91to1.06,I²=70%;2trials,56participants,GRADE:verylowquality)orparticipationlevel(SMD-0.11,95%CI-0.56
to0.33,I²=0%;2trials,79participants,GRADE:lowquality)butsubstantialheterogeneityontheformer.Analysesofimmediate
post-interventionoutcomesprovidednoevidenceofanyshort-termbenefitonactivity(SMD0.29,95%CI-0.07to0.66,I²=0%;
3trials,117participants,GRADE:verylowquality);orparticipation(SMD-0.24,95%CI-0.94to0.45;1study,32participants)
levelsofmeasurement.
Therewasastatisticallysignificanteffectfavouringinterventionattheimmediate,impairmentlevelofmeasurement(SMD0.47,95%
CI0.02to0.92,P=0.04,I²=0%;4trials,99participants,GRADE:verylowquality)butonlyoneofthesefourtrialshadalowrisk
ofbias.
Authors’conclusions
Wefoundnodefinitive,adequatelypoweredRCTsofinterventionsforpeoplewithdysarthria.Wefoundlimitedevidencetosuggest
theremay beanimmediatebeneficial effectonimpairmentlevelmeasures;more, higherquality researchisneededtoconfirmthis
finding.
Althoughweevaluatedfivestudies,thebenefitsandrisksofinterventionsremainunknown andtheemergingevidencejustifiesthe
needforadequatelypoweredclinicaltrialsintothiscondition.
Peoplewithdysarthriaafterstrokeorbraininjuryshouldcontinuetoreceiverehabilitationaccordingtoclinicalguidelines.
PLAIN LANGUAGE SUMMARY
Interventionsforspeechproblems(dysarthria)afterstrokeorothernon-progressivebraininjury
Reviewquestion
Doesanytypeoftreatmenthelppeoplewhohavedifficultyspeakingclearlyafterastrokeorothertypesofbraininjuryacquiredduring
adulthood?
Background
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 2
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Braindamagecausedbystroke,injuryorothernon-progressivediseasecanmakespeechunclearanddifficultforlistenerstounderstand.
This condition is known as dysarthria and it occurs when face, tongue, and throat muscles are weak, slow, and unco-ordinated.
Dysarthriacancausepeoplewhoareaffectedtoloseconfidencewhentalkingandbecomesociallyisolated,evenifothersseesymptoms
asmild.Peoplewithdysarthriadonothavedifficultiesthinking,remembering,orretrievingwords.
Treatmentisusuallyprovidedbyaspeechandlanguagetherapistorspeechpathologistandinvolvesadviceandeducationplusstrategies
andexercisestoincreaseclarityofspeechandtocopewithsocialinteraction.Othertypesoftreatmentusedincludeacupunctureor
brainstimulation.
Wewantedtofindoutifanytreatmentswork,iftheeffectsarelonglasting,andifso,whichworksbest,whentreatmentshouldstart,
howfrequenttreatmentshouldbe,andforhowlong.Tofindoutwesearchedfor,evaluated,andsummarisedthequalityoftheexisting
researchonthistopic.
Searchdate
WesearchedtheliteratureuptoMay2016.
Studycharacteristics
We includedfive small trialsthatrandomised only 234 people,almost allwith stroke. Two trialsinvestigated dysarthria treatment
versusanattentioncontrolandthreecomparedonetreatmentwithusualcare.Therewerenotrialsthatcomparedonetreatmenttono
treatment.
Keyresults
Wefoundfewrandomisedcontrolledtrialsofdysarthriatreatment,andthosethathavebeenconductedinvolvedsmallnumbersof
participants,orwerenotadequatelydesignedorhadseriousreportingflaws.
Wecomparedmanydifferentmeasuresatvarioustimepointsaftertreatment,socautionisrecommendedwheninterpretingresults.
Wefoundnoevidenceofeffectivenessonmostmeasures,includinglong-lastingimprovementineverydaycommunicationabilities.A
positivefindingwasshort-termimprovementinmusclemovement,suchastongueandlipcontrol.However,thisresultisnotreliable
becauseitwasbasedonsmallnumbersofpeople,andwefoundconcernsabouttheconductandreportingofsometrials.Thisfinding
needstobeinvestigatedinabigger,betterdesignedtrial.
Wefoundinsufficientevidencetotelluswhetheranyonetreatmentisbetterthananyotherorwhethertreatmentisbetterthangeneral
support,ornotreatment.Wefoundnostudiesthatexaminedtiming,duration,orintensityoftreatment.Thisisaclinicallyimportant
questionandshouldbeconsideredinfuturetrials.
Qualityoftheevidence
The includedtrialsvariedinquality butallincluded smallnumbers of participants. Overall,studies wereratedaslow toverylow
qualityevidence.
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 3
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
Dysarthriainterventioncomparedwithanotherintervention,attentioncontrol,placeboornointerventionforpeoplewith
dysarthriaafterstrokeorotheradult-acquired,non-progressivebraininjury
Patientorpopulation:adultswithdysarthriafollowingstrokeorotheradult-acquired,non-progressivebraininjury
Settings:any
Intervention:dysarthriaintervention
Comparison:anotherintervention,attentioncontrol,placeboornointervention
Outcomes Standardised mean Noofparticipants Qualityoftheevidence Comments
difference (studies) (GRADE)
(95%CI)
Dysarthriaintervention 0.18[-0.18,0.55] 116participants ⊕⊕(cid:13)(cid:13) Very small numbers
versus any control: 3RCTs low and none of the stud-
persisting effects, ac- iesareadequatelypow-
tivitylevel ered
Only two of the three
studies considered low
riskof bias
Dysarthriaintervention 0.07[-0.91,1.06] 56participants ⊕(cid:13)(cid:13)(cid:13) Very small numbers,
versus any control: 2RCTs verylow none of the studies
persisting effects, im- are adequately pow-
pairmentlevel ered. Only one of the
twostudiesconsidered
lowriskof bias
Dysarthriaintervention -0.11[-0.56,0.33] 79participants ⊕⊕(cid:13)(cid:13) Both studies consid-
versus any control: 2RCTs low ered low risk of bias
persistingeffects,par- butverysmallnumbers
ticipationlevel and neither study ade-
quatelypowered
Dysarthriaintervention 0.16[-0.23,0.54] 106participants ⊕⊕(cid:13)(cid:13) Very small numbers
versus any control for 3RCTs low and none of the stud-
stroke subgroup: per- iesareadequatelypow-
sistingeffects,activity ered
level Only two of the three
studies considered low
riskof bias
Dysarthriaintervention 0.29[-0.07,0.66] 117participants ⊕(cid:13)(cid:13)(cid:13) Very small partici-
versusanycontrol:im- 3RCTs verylow pant numbers, not ad-
mediateeffects,activ- equatelypowered.Only
itylevel oneofthethreestudies
considered to be low
riskof bias
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 4
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Dysarthriaintervention 0.47[0.02,0.92] 99participants ⊕(cid:13)(cid:13)(cid:13) Very small partici-
versusanycontrol:im- 4RCTs verylow pant numbers, not ad-
mediate effects, im- equatelypowered.Only
pairmentlevel one of thefour studies
considered to be low
risk of bias. This com-
parisonshowsasignif-
icanteffect
GRADEWorkingGroupgradesof evidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateof effect.
Moderate quality:Further research is likely to have an important impact on our confidence in the estimate of effect and
maychangetheestimate.
Lowquality:Furtherresearchis verylikelyto haveanimportant impact onour confidenceintheestimateof effect and is
likelytochangetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
BACKGROUND milddysarthria,buthighlevelsofcommunicationbeforetheirill-
ness,mayexperiencepsychologicalimpairmentassevereassome-
onewithmoreseveredysarthria.
Descriptionofthecondition
Dysarthriaisaspeechdisorderaffectingintelligibilityduetodis-
Descriptionoftheintervention
turbances in neuromuscular control. Dysarthriaaffectsapproxi-
mately20%to30%ofstrokesurvivors(Lawrence2001;Lubart Behaviouralinterventionsbyaspeechandlanguagetherapistor
2005;Warlow2008)and10%to60%ofthosewhosurvivetrau- speechlanguagepathologistarethemainstayofdysarthriatreat-
maticbraininjury.Itcanoccurinadultsasanoutcomeofmenin- ment. The primary aim is to maximise the patient’s ability to
gitis, encephalitis, post-surgical meningioma, and acoustic neu- communicatewithothers.UKtreatmentguidelinesfordysarthria
roma(Sellars2005). (Taylor-Goh2005)recommendthatbehaviouralinterventionsad-
Dysarthria is defined as a neurologic motor speech impairment dressalldimensions of theInternational Classification of Func-
causing thespeechmusculature tobe slow, weakand/or impre- tioning,DisabilityandHealth(ICF)Framework;impairment,ac-
cise(Duffy2013).Thiscausespoorco-ordinationofmovements tivityandparticipation(WHO2001).Impairmentlevelexercises
involvingbreathing,voiceproduction,resonance,andoralartic- toimprovethestrength,speed,orfunctionoftheimpairedmus-
ulation(Yorkston1996).Peoplewithdysarthricspeechtypically culaturemaybeused.Theseareusuallynon-speechandoro-mo-
sound lessintelligible or slurredbecause of poor oral control of tor movementsof affectedmusclesor muscle groups. This may
articulators,particularlythetongue.Speechcanalsobequiet,un- includeexternalstimulation ofthemusclessuchasapplyingice
derpowered,andlackingexpressivenessbecauseofrespiratorycon- packs,brushingtheskin,acupuncture(traditionalandelectrical),
trolorimpairedvocalcordfunction.Dysarthriaincludesawide ortranscranialmagneticstimulationofthebrain.Attheactivity
severityrange;somepeoplemaybemostlyunintelligibletothelis- level, compensatory strategies to increase intelligibility through
tener;peopleatthemilderendoftherangemayexperiencelapses purposeful speech production such as over-articulation or slow-
inspeechaccuracy,orfatigue,butspeechisgenerallyintelligible. ing rate of speech may be used. In addition alternative ways to
Dysarthriaimpactsbeyondimpairedcommunication.Itcanneg- communicate,orsupportspeech,maybeusedsuchasanalpha-
ativelyaffectpsychologicalwellbeing,socialparticipation,andre- betchartorcomputerswithartificialvoicesoftware.Participation
habilitation (Brady 2011; Dickson 2008; Tilling 2001). Brady levelapproachesmayusefacilitatedgroupwork,education,and
2011 found thatthepsychological impactcanbe influencedby feedbacktosupportthepsychologicalhealthofpeoplelivingwith
pre-morbidlevelsofcommunicationdemands.Anindividualwith dysarthriaoradvicetoacommunication partnermaybeimple-
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 5
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
mented. METHODS
Howtheinterventionmightwork Criteriaforconsideringstudiesforthisreview
TheinterventionsattheimpairmentlevelintheDescriptionofthe
interventionarelikelytobefocusedontherecoveryofimpaired
movementthroughexercisestoincreasestrength,range,precision Typesofstudies
andspeedofmovementrequiredforspeech.Treatmentcanutilise Weincludedrandomisedcontrolledtrials(RCTs)ofinterventions
non-speechormoretypicallyspeech-focusedmovementtasks.In- toimprove non-progressive dysarthricspeechin adultswith ac-
terventionforlimbrehabilitationindicatessomeassociation be- quired brain injuries, including comparisons with no interven-
tween muscle strength and function of movement (Langhorne tion,anotherintervention(whichmaybethesameintervention
2009)butitisnotknownwhetherthisisthecaseformusclesin- approachbutalternativemethod,theory,timing,durationorfre-
volvedinspeech.Interventionsmayexamineintensityofinterven- quency), attention control, or placebo. We included data only
tionandmaycomparequantity,durationandfrequencyofinput. fromthefirstphaseofcross-overtrialstoavoidcontamination.
Weknowfrompost-strokeresearchmoregenerallythatincreased
intensityoftreatmentmaybeakeyelementinrecoverybutthe
optimumfrequency,durationandquantityofinterventionisnot Typesofparticipants
known(IntercollegiateStrokeWorkingParty2016). Adults (aged over 18 years) diagnosed with non-progressive
The interventions at the activity and participation levelas out- dysarthriafollowingacquiredbraininjury,principallystrokeand
lined in the Description of the intervention are likely to focus traumaticbraininjury,atanytimesincestrokeonsetortrauma
on strategies or patient specific goals to improve speech intelli- event.
gibility that relate to a meaningful communication activity for
thatperson.Strokeguidancesuggeststhatgoalsettingshouldbe
usedasarehabilitationtool(IntercollegiateStrokeWorkingParty Typesofinterventions
2016).Thismayincludereducingrateofspeechwhentalkingon We considered any type of intervention for acquired dysarthria
thephone,employingpurposefuluseofspeechintonationtodis- includingbehaviouralorpsychologicalapproaches,useofdevices
tinguishstatementsfromquestionsinconversation,oradviceto and medication, excluding surgical interventions. Interventions
thekeycommunicationpartner.Grouporindividualworktotar- could be carried out by any healthcare professional, healthcare
getconfidenceinuseofcommunicationisanothertreatmentap- staff,trainedvolunteer,familymemberorcarer,orthepersonwith
proach,whichmayincorporateprinciplesofpsychologicalinter- dysarthria.
ventionssuchasmotivationalinterviewing.Environmentalmod- InterventionsaddressedanyleveloftheInternational Classifica-
ificationandeducationcanalsobeutilisedtooptimisecommuni- tion of Functioning Disability and Health(ICF)(WHO 2001)
cationeaseandsuccessinagivencontextsuchasafamily,hospital includingthefollowing.
ornursinghomesetting. • Impairmentlevel:interventionsspecificallytargetingthe
impairmentoffunction,e.g.non-speechandoro-motorexercises
toimprovespeed,range,strength,accuracyofspeech/respiratory
Whyitisimportanttodothisreview musculature,externalstimulationofthemusclessuchas
applyingicepacks,brushingtheskin,transcranialmagnetic
Thepreviousversionofthisreviewfoundnostudiesthatmetin-
stimulationofthebrain,acupuncture(traditionalandelectrical).
clusioncriteria(Sellars2005).Furthertrialshavesincebeenpub-
• Activitylevel:interventionstoincreaseintelligibilityby
lished,andthisupdatebroadenedthescopeofthesearchstrategy
modifyingexistingspeech(e.g.modifyingrateofspeech)orthe
appliedbySellars2005toincludeallinterventionscarriedoutby
useofaugmentativeoralternativecommunicationdevicese.g.
anyhealthprofessional,peoplewithdysarthria,atrainedindivid-
lighttechaids(non-technicalmaterialssuchasanalphabet
ual,oranyothernewapproachestotreatment.
chart)andhightechaids(suchastext-to-talkcomputerdevices).
• Participationlevel:interventionsaimedatsupportor
educationfortheindividualwithdysarthriaorprogrammesfor
peoplewithdysarthriaandtheirconversationalpartnersor
OBJECTIVES conversationaltrainingaswellasanypsychologicalapproachesto
treatmentthatfocusonincreasingsocialparticipation.
Toassesstheeffectsofinterventionstoimprovedysarthricspeech
followingstrokeandothernon-progressive adult-acquired brain Wedidnotplaceanyrestrictionsonfrequency,intensity,ordura-
injurysuchastrauma,infection,tumourandsurgery. tionoftheinterventions.
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 6
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Typesofoutcomemeasures Searchmethodsforidentificationofstudies
Seethe’Specializedregister’sectionintheCochraneStrokeGroup
module. We did not impose any language restrictions and we
Primaryoutcomes soughttranslationsfornon-Englishlanguagestudies.
Theprimaryoutcomemeasureforthisreviewwasthelong-term
effectivenessofthedysarthriainterventiononeverydayspeech(ac- Electronicsearches
tivitylevel,persistingeffect)comparedwithanycontrol(another
We searched the Cochrane Stroke Group Trials Register (last
intervention, attention control or placebo, or no intervention).
searchedby the Managing Editor to May 2016), the Cochrane
Attemptstoobjectivelymeasureeverydayspeechareusuallybased
CentralRegisterofControlledTrials(CENTRAL,CochraneLi-
on listener perception grading scales such as dysarthria therapy
brary2016,Issue4;Appendix1),MEDLINE(1946toMay2016;
outcomemeasures(Enderby1997)orthecommunicationeffec-
Appendix2),Embase(1974toMay2016;Appendix3),CINAHL
tivenessmeasure(Mackenzie2007).Wedefinedevidenceofaper-
(1937toMay2016;Appendix4),PsycINFO(1800toSeptem-
sistentbeneficialeffectasaroundsixmonthspost-interventionex-
ber 2016; Appendix 5) and LLBA (1976 to November 2016;
tractedasmeasurestakenbetweenthreeandnine monthspost-
Appendix6)usingcomprehensivesearchstrategies.
intervention.
We searched major trials registers for ongoing trials including
Whentrialsusedmorethanoneoutcomemeasureattheactivity
theWorldHealthOrganizationInternationalClinicalTrialsReg-
level,wetooktheprimaryoutcomeasspecifiedbythetrialinves-
istryPlatform(who.int/ictrp/search/en/),theISRCTNregistry(
tigators.Ifatrialhadnotspecifiedaprimaryoutcomemeasure,
isrctn.com/),ClinicalTrials.gov(clinicaltrials.gov/)andtheStroke
wecheckedifameasureoffunctionalcommunicationhadbeen
TrialsRegistry(strokecenter.org/trials/).
usedatthespecifiedtimepoints.
Searchingotherresources
Secondaryoutcomes Inanefforttoidentifyotherpublished,unpublished,andongoing
Secondaryoutcomesincludedexploringeffects: trialswehandsearchedthereferencelistsofrelevantarticlesand
• atothermeasurementlevels(e.g.impairment, contactedacademicinstitutionsandotherresearchers.
participation);
• atothertimepoints(e.g.immediatepost-intervention);
• comparedwithspecificcontrolgroups(e.g.another Datacollectionandanalysis
intervention,attentioncontrolorplacebo,ornointervention);
• forclinicalsubgroups(e.g.stroke,braininjury);
• forstudiesassessedatlowriskofbias.
Selectionofstudies
Ourselectioncriteriawereasfollows.
Secondaryoutcomemeasureswereasfollows.
• Researchparticipantswithdysarthriafollowingstrokeor
• Communicationatimpairmentlevel(immediateand
otheradult-acquired,non-progressivebraininjury.
persisting):speechimpairmentmeasuree.g.FrenchayDysarthria
• Interventionsdesignedtoreducethedysarthriaorits
AssessmenteditionIorII(Enderby1983),IowaOral
impactonlivingwithdysarthria.
PerformanceInstrument(IOPI)(IOPI2005),measuresof
• RCTs.
intelligibility(e.g.AssessmentofintelligibilityofDysarthric
Speech)(Yorkston1984),acousticandperceptualmeasuresof Oneauthor(CM)excludedanyobviouslyirrelevantreportsfrom
voiceandspeech(e.g.vocalprofileanalysis,pitch,loudness,air thetitlesandabstractsretrievedinthesearch.Threeauthors(CM,
flow,soundspectography). AB, PC) independently examined the remaining abstracts and
• Communicationatactivitylevel(immediate):activity thenthe full-text to determine eligibility and exclude irrelevant
measure(e.g.DysarthriaTherapyOutcomeMeasure)(Enderby reports.Weresolveddisagreementsthroughdiscussion.Noreview
1997),listeneracceptabilitymeasures. author examined their own study. We pursued finding confer-
• Communication-relatedqualityoflife(immediateand enceproceedingsanddissertations thatweredifficulttoretrieve
persistingparticipationlevel):patientperceptionofimpact(e.g. usingemailcontacts,universityalumnisocieties,andconference
DysarthriaImpactProfile)(Walshe2009);Communication committees.Wearrangedforreportspublishedinlanguagesother
OutcomesafterStrokeScale(Long2008). thanEnglishtobetranslatedwhererequired.Wherepossible,we
• Genericqualityoflifemeasures:moodscales(e.g.Hospital contactedauthorsofstudiesforclarificationtoinformdiscussions
AnxietyandDepressionScale)(Zigmond1983);subjective aroundeligibility.Allauthorsagreedfinaldecisionsonincluded
healthscales(e.g.EuroQol,SF-36)(Herdman2011). studiesandproceededtodatacollection.Thestudieswejudged
Interventionsfordysarthriaduetostrokeandotheradult-acquired,non-progressivebraininjury(Review) 7
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.