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.