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Shaping innovative services: Reflecting on current and future practice
100
JCPSLP
Volume 19, Number 2 2017
Journal of Clinical Practice in Speech-Language Pathology
Rachel Wenke
(top) and
Melissa Lawrie
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
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.
What’s the evidence?
Computer-based therapy: How does it compare to
clinician-delivered treatment in aphasia?
Rachel Wenke and Melissa Lawrie