JCPSLP Vol 19 No 2 2017

Shaping innovative services: Reflecting on current and future practice

What’s the evidence? Computer-based therapy: How does it compare to clinician-delivered treatment in aphasia? Rachel Wenke and Melissa Lawrie

C omputer therapy is increasingly used as an option to increase therapy intensity for people with aphasia, requiring fewer resources than traditional clinician- delivered models. Rapid technological improvements have seen significant developments in the use of computers for aphasia rehabilitation (van de Sandt-Koenderman, 2011). An abundance of computer programs and iPad applications are currently available in aphasia rehabilitation (Holland, 2014; Hoover & Carney, 2014) targeting both impairment and functional areas of language, and innovations such as virtual reality are emerging (Marshall et al., 2016) Such innovations may be a supplement to or a replacement of clinician-delivered treatment (Zheng, Lynch, & Taylor, 2016). Indeed, as technology continues to advance, the role of the clinician as the agent of therapy is predicted to potentially shift to one more of an “advisor and orchestrator of the rehabilitation process” (van de Sandt- Koenderman, 2011, p. 26). Rather than delivering treatment, the clinician may instead select appropriate therapy programs for clients to undertake independently thus also empowering a client’s self-management. While overall perceptions of computer-based treatment from clinicians and people with aphasia are positive (Davis & Copeland, 2006; Finch & Hill, 2014), stakeholders invested in aphasia therapy including clients and their families, service managers and other health professionals may still ponder the efficacy of computer therapy compared to more traditional modalities such as clinician-delivered treatment. This “What’s the evidence” column will explore this question further. Clinical scenario As a speech-language pathologist working in a subacute tertiary hospital outpatient service, you are referred a 68-year-old woman who presents with a moderate–severe fluent aphasia 3 months following a stroke. She and her husband are very motivated to improve her communication but due to current service constraints you are able to see her only twice a week for therapy. Your line manager has suggested offering clients extra computer therapy to increase therapy intensity. You suggest this to your client, and while she and her husband are receptive to the idea of computer therapy, her husband asks whether computer therapy will be as effective as individual therapy provided by a speech-language pathologist.

Response To answer this question you decide to review the current evidence. As the chronicity of and type of aphasia that you manage in your caseload varies, you choose to keep your question more broad rather than focusing on a specific type or chronicity of aphasia. You use the PICO approach (Armstrong, 1999) to formulate an answerable clinical question as follows: In people with aphasia [ population ], what is the effectiveness of computer-based therapy [ intervention ] compared to clinician-delivered therapy [ comparator ] in improving communication function [ outcome ]? You take this PICO question to your hospital librarian who assists you in searching the current evidence. The search strategy used a combination of synonyms of keywords from the “P” and “I” of your PICO question (i.e., population and intervention) as shown in Table 1. You decide to include iPad-based as well as computer-based therapy as well as they are both technology delivered and you have access to iPads within your workplace. Database filters were applied to English only studies from 2010–2017 with treatment or review articles only and the Boolean phrases “TI” and “AB” were added to database searches to ensure the keywords appeared in either the Title or abstract of the paper. The librarian transferred results into an Endnote library and duplicates were removed, with a total of 280 unique studies. The search retrieves one recent systematic review which answers your clinical question (Zheng et al., 2016), being the highest level of evidence (NHMRC level I). Although the systematic search within Zheng et al.’s review was undertaken in August 2013, your search did not retrieve any additional studies specific to your clinical question that were not already included in Zheng’s review. Rather, your search showed the breadth of technology-based therapies available in aphasia including use of iPad and virtual-based therapies, predominately reported in studies using pre-post single group designs. The review article by Zheng et al. (2016) synthesised data from three studies (two RCTs and one within subjects design), totalling 38 participants (receiving computer therapy) and 22 participants receiving clinician-delivered therapy, all with chronic aphasia. The three studies compared different computer interventions with clinician- delivered treatment which was stated to be identical to the

Rachel Wenke (top) and Melissa Lawrie

100

JCPSLP Volume 19, Number 2 2017

Journal of Clinical Practice in Speech-Language Pathology