VISTA SLT Speech and Language Therapy Blog

Aphasia Therapy intensity: the gap between guidelines and provision

Aphasia, a language difficulty which occurs following stroke or brain injury, can be a chronic condition for many. Despite this, research clearly shows us that intensive Speech and Language Therapy can significantly reduce the degree of difficulty stroke survivors face in everyday communication. In this blog, we will reflect on the current evidence and guidelines around Speech and Language Therapy intensity and how private Speech Therapy can be a vital piece of the jigsaw.

What do the guidelines recommend?

The national clinical guidelines for stroke rehabilitation were updated in 2023. These guidelines contained some key updates in relation to Speech and Language Therapy for stroke related communication difficulties.

The guidelines state that people with Aphasia after stroke should have the opportunity to access Speech and Language Therapy as frequently as possible and for as long as they continue to make meaningful gains. It is also stipulated that intensive Speech and Language Therapy programmes may be considered from 3 months post stroke for those who can tolerate an intensive approach, and that people with Aphasia should be supported to access digital therapies to enhance their rehabilitation.

In the updated guidelines, more consideration is given to encouraging opportunities to practice everyday communication as part of rehabilitation. This also feeds into another important aspect of the new guidelines: vocational rehabilitation. This is the process of supporting stroke survivors to work towards a return to paid or voluntary work. Vocational rehabilitation is usually a collaborative approach between stroke survivors, their employers and relevant therapists from the stroke multidisciplinary team.

What are meaningful gains?

What is considered meaningful will be different to each stroke survivor. As we know, the severity and impact of Aphasia is varied and so what is felt to be a significant improvement will also vary. It is recognised that people with Aphasia can make improvements months and years after a stroke. Meaningful gains from Speech and Language Therapy could potentially continue throughout a person’s life post-stroke.

What does the guidance say about ‘rehab potential’?

The updated guidelines indicate that Speech and Language Therapists should assess an individual’s potential to benefit from therapy on a case-by-case basis, collaborating with the stroke survivor and those around them to determine relevant goals and a suitable approach. Therapists should avoid making judgements about the potential benefit of therapy too soon after a stroke, or assume that therapy would be unsuccessful for a person who has long term stroke-related communication difficulties. Instead, stroke survivors should be considered to have the potential to benefit from rehabilitation at any point after their stroke.

Why do these guidelines matter?

Guidelines are formed based on scientific research and observations and feedback from lived experience. The clinical guidelines for stroke form the basis for which services should strive to operate and help NHS Speech and Language Therapy teams to make the case for increased investment in their services.

Working in line with the clinical guidelines for stroke ensures high quality Speech and Language Therapy for stroke survivors, giving the best opportunity for improvement in communication skills. Communication is vitally important for independence, confidence and emotional well-being. Research by Hilari, Needle and Harrison in 2012 showed that there was a relationship between the severity of a person’s Aphasia and their overall health, with those who have more severe Aphasia often having poorer overall health. This stresses the importance of Speech and Language Therapy in supporting people with Aphasia to communicate their needs and thrive in everyday life.

A recent large-scale study (Brady et al 2023) explored the current research around the optimal ‘dosage’ of Speech and Language Therapy for the greatest improvement for people with Aphasia. Overall, the review concluded that the best recovery occurs when:

• Therapy starts within 28 days of the onset of Aphasia
• 20 – 50 hours of speech and language therapy is provided in total
• Tasks are practised at home

The study also determined that 2 – 4 hours of therapy a week, delivered over 4 – 5 days is optimal for general language improvement.

The stroke guidelines in relation to the provision of intensive therapy are in keeping with the above research. Interestingly, this research also found that the same benefits were seen when Speech and Language Therapy was conducted virtually, or when therapy apps were used alongside direct work with a Speech and Language Therapist. The study concluded that people with Aphasia who were over the age of 55 made the greatest improvements, although people over 75 still made improvements with Speech and Language Therapy support.

The current landscape and the profession’s response

While research and clinical guidelines stress the importance of intensive Speech and Language Therapy for people with Aphasia, the profession recognises ongoing challenges in delivering this intensity.

The Royal College of Speech and Language Therapists (RCSLT), our regulatory body, has highlighted significant concerns about high vacancy rates for Speech and Language Therapy positions in the NHS. This puts pressure on the system, making it difficult for NHS teams to manage waiting lists and meet demand. As a result, many NHS Speech and Language Therapy teams are either forced to impose limitations on the amount of therapy they can provide, or people with Aphasia face lengthy waits until NHS Speech and Language Therapy support starts at home.

The RCSLT continues to raise awareness of the challenges the Speech Therapy profession is facing, working with its membership to gather information and lobbying parliament. As long as these issues persist, it can be challenging to advocate for the right level of support for you, or a loved one.

Where does private Speech and Language Therapy fit in?

We covered the benefits of independent Speech Therapy in detail in our previous blog post. However, it is important to reiterate that private Speech and Language Therapists can often enable more intensive therapy and bring with them considerable experience to share with their clients. VISTA SLT’s co-directors Gemma and Lisa have over 20 years’ experience of working with people with Aphasia.

At VISTA SLT, as with many private therapy teams, we are very comfortable working collaboratively with NHS Speech Therapists who may be supporting you, or your loved one. This can enhance both the quality and the intensity of the therapy provided. We also frequently work with clients in the short to medium term, to bridge the gap between hospital discharge and community NHS Speech and Language Therapy starting.

The decision to end private Speech and Language Therapy is firmly in your hands. At VISTA SLT, we pride ourselves on our high regard for ethics. This means that we will only encourage continuation of sessions where we perceive there will be a benefit to you, or your loved one, not for our financial gain. Please do not hesitate to contact us if you, or a loved one needs support with Aphasia following a stroke or brain injury.

References

Brady et al (2023) Complex speech-language therapy interventions for stroke-related aphasia: the RELEASE study incorporating a systematic review and individual participant data network meta-analysis: https://www.journalslibrary.nihr.ac.uk/hsdr/RTLH7522#/abstract

Plain language summary of the above research: https://evidence.nihr.ac.uk/alert/therapy-for-language-problems-after-a-stroke-is-most-effective-when-given-early-and-intensively/

Hilari K, Needle J and Harrison K (2012) What Are the Important Factors in Health-Related Quality of Life for People with Aphasia? A Systematic Review: https://openaccess.city.ac.uk/id/eprint/1095/1/

National Clinical Guideline for Stroke for the UK and Ireland. London: Intercollegiate Stroke Working Party; 2023 May 4: www.strokeguideline.org

Royal College of Speech and Language Therapists bulletin winter 2023/24 edition. Article ‘Keeping Up’ – pages 32 and 33: https://www.rcslt.org/wp-content/uploads/2023/11/Bulletin-Winter-23-24_FULL-LRC.pdf

Royal College of Speech and Language Therapists (2024) Vacancy rates in speech and language therapy remain troublingly high at 21%: https://www.rcslt.org/news/vacancy-rates-in-speech-and-language-therapy-remain-troublingly-high-at-21/

Stroke Association Communication problems after stroke guide (updated 2023): https://www.stroke.org.uk/stroke/effects/aphasia/communication-tools#Communication-support-pack