Evidence reviews for computer-based tools for speech and language therapy

Evidence reviews for computer-based tools for speech and language therapy

Stroke rehabilitation in adults (update)

Evidence review K

NICE Guideline, No. 236

London: National Institute for Health and Care Excellence (NICE); 2023 Oct.

ISBN-13: 978-1-4731-5460-5

1. Computer-based tools for speech and language therapy

1.1. Review question

In people with aphasia after stroke, what is the clinical and cost effectiveness of computer-based tools to augment speech and language therapy?

1.1.1. Introduction

Speech and language therapy after stroke is provided in hospitals and in the community to help people with resulting communication disorders to improve their speech/language impairment, their ability to communicate and participate in their everyday roles and activities. It is generally accepted that improvement requires practice, and that rehabilitation is more effective in higher doses. Providing therapy and practice opportunities in sufficient dose can be a challenge in clinical practice due to limitations on therapy resources and distance between patients and therapists in some community settings. In addition, people with communication needs often wish to continue to work on their speech/language for longer than therapy is available for and look for alternative ways to support them in doing this. A growing number of computer software programmes, apps and online therapy tools are commercially available (see aphasia therapy software finder https://www.aphasiasoftwarefinder.org). These tools are used by some therapists and patients to increase therapy practice opportunities either as home practice between therapy sessions or after face-to-face therapy has ended. Computer tools also offer a large range of practice material, practice material can be personalised, and some tools provide useful feedback.

This review has been prompted by publication of new evidence about effectiveness, and by an increasing interest in using computer tools to increase dose and to provide therapy remotely as was required during the COVID-19 pandemic.

1.1.2. Summary of the protocol

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Twenty-two randomised control trial studies (including 2 cross-over trials and 3 quasi-randomised trials) (27 papers) were included in the review;⁴^, ⁶^–⁸^, ¹¹^, ¹³^, ¹⁴^, ¹⁹^, ²⁰^, ²³^–²⁸^, ³³^, ³⁷^, ³⁹^, ⁴²^, ⁴⁵^, ⁴⁷^, ⁴⁸ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

3 quasi-randomised trials⁶^, ²⁵^, ⁴⁷ were included. Due to the limited evidence investigating computer-based tools for speech and language therapy, it was agreed to include these studies but ensure that they were downgraded sufficiently for risk of bias due to the randomisation process. Evidence was available for all outcomes apart from carer generic health-related quality of life.

Population factors

The majority of studies included people with aphasia⁴^, ⁶^–⁸^, ¹¹^, ¹³^, ¹⁴^, ¹⁹^, ²⁰^, ²³^–²⁶^, ³³^, ³⁹^, ⁴²^, ⁴⁷^, ⁴⁸. However, studies occasionally included a mixture of people with aphasia or cognitive communication²⁷, mixture of people with aphasia or aphasia and apraxia of speech³⁷, people with dysarthria²⁸ or people with apraxia of speech⁴⁵. Severity of communication difficulty was rarely reported, but when it was included people with mild communication difficulties³⁹ or with a mixture of different severities³⁷^, ⁴². Additionally, the majority of studies included people in the chronic phase after stroke⁴^, ⁶^–⁸^, ¹¹^, ¹³^, ¹⁴^, ¹⁹^, ²⁵^–²⁷^, ³⁷^, ³⁹^, ⁴⁵^, ⁴⁷ with only occasional studies including people in the subacute phase or a mixture of people in the chronic and subacute phases²⁰^, ²³^, ²⁸^, ³³^, ⁴⁸

Types of computer-based tools

The types of computer-based tools used varied between studies with no consistently used interventions. The method of therapy used varied including:

Word finding therapy⁴^, ¹⁹^, ³⁷^, ⁴⁷
Reading therapy⁶^–⁸
Comprehension therapy¹⁴
Expressive language/communication²⁶^, ⁴⁵
Articulation therapy²⁸
Other (cognitive therapy)²³
Combinations of approaches¹¹^, ¹³^, ²⁰^, ²⁴^, ²⁵^, ²⁷^, ³³^, ³⁹^, ⁴²^, ⁴⁸

There was a mixture of therapies being delivered in person⁶^, ⁷^, ¹¹^, ¹³^, ¹⁴^, ²⁰^, ²³^, ³⁹^, ⁴², remotely⁴^, ⁸^, ²⁴^–²⁸^, ³³^, ³⁷^, ⁴⁵^, ⁴⁷^, ⁴⁸ (implementing telerehabilitation technology) or a combination of both³⁷.

Intensity of therapy

The therapies were delivered at a range of different intensities. Studies investigated the following total number of therapy hours:

≤10 hours²⁷^, ⁴⁵^, ⁴⁷
11-20 hours⁶^, ¹¹^, ²⁰^, ²³^, ³³
21-30 hours⁴^, ⁷^, ²⁵^, ²⁶^, ³⁹^, ⁴⁸
≥30 hours⁸^, ¹³^, ¹⁹^, ²⁴^, ⁴²
Mixed (intensity could be varied)²⁸
Not stated/unclear³⁷

Inconsistency

The majority of outcomes included only one study. However, occasionally meta-analysis was possible. Occasionally this would lead to heterogeneity. This could not be resolved by subgroup or sensitivity analysis, with the majority of outcomes containing an insufficient number of studies to allow valid conclusions on the analyses to be drawn. Therefore, outcomes were downgraded for inconsistency.

See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

Two Cochrane reviews³^, ⁴⁶ were identified and excluded from this review. For Brady 2016³ this was due to the review including all speech and language therapy studies for people with aphasia, rather than just those that had computer-based tools being implemented. For West 2005⁴⁶ this included all speech and language therapy studies for people with apraxia of speech, rather than just those that had computer-based tools being implemented. In both cases, the citation lists of both studies were checked for relevant studies which were included if appropriate.

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.5.1. Summary matrix

Table 3

Summary matrix of computer-based tools for speech and language therapy compared to each comparison groups.

1.1.6. Summary of the effectiveness evidence

Table 4

Clinical evidence summary: computer-based tools for speech and language therapy compared to speech and language therapy without computer-based tools (usual care).

Table 5

Clinical evidence summary: computer-based tools for speech and language therapy compared to social support/stimulation.

Table 6

Clinical evidence summary: computer-based tools for speech and language therapy compared to no treatment.

Table 7

Clinical evidence summary: computer-based tools for speech and language therapy compared to placebo.

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

Two health economic studies were included in this review.²¹^, ²² These studies were economic evaluations of a pilot feasibility trial (CACTUS)³⁹ and randomised controlled trial (Big CACTUS)³⁴of the StepByStep computer program both of which were included in the clinical review. Both economic analyses were included in the review as:

the CACTUS trial assessed computer exercises (3 days per week was recommended over 5-month period) that contained a combination of word finding and reading therapies,
while BIG CACTUS assessed word-finding therapy computer exercises only and recommended that participants practice daily over 6-period.

These studies are summarised in the health economic evidence profile below (Table 8) and the health economic evidence table in Appendix H.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

Table 8

Health economic evidence profile: Computer-based tools for speech and language therapy versus usual care.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness.

Table 9

Unit costs of health care professionals who may be involved in delivering interventions involving computer-based tools for speech and language therapy.

Interventions involving computer-based tools for speech and language therapy require additional resource use over usual care. Studies included in the clinical review reported varied resource use (see Table 2 for details). Key differences in resource use were due to the following factors:

The type of computer tool used varied across studies; Table 10 provides example costs associated with some of the tools that were assessed in the clinical review, with the cost per patient depending on both the type of software and whether multiple licences are purchased at once.
Variation in method of delivery of therapy sessions: there was a mixture of studies assessing therapies delivered either in person or remotely, with one reporting a combination of both³⁷ Therapy delivered remotely is considered to be less resource intensive compared to face-to-face therapy.
The frequency and duration of the intervention being delivered, with sessions ranging from 20-90 minutes, occurring 2-6 days per week, In the included clinical studies, the interventions were delivered for between 4-13 weeks.
Staff who delivered the intervention varied as studies reported either physiotherapists, occupational therapists, or trained instructors. Palmer 2020³⁸ reported the use of SLTs and SLT assistants as well as trained volunteers to deliver the intervention.
Study setting: interventions were conducted in hospitals, community centres, and outpatient rehabilitation centres. Non-clinical settings will incur lower or no costs compared to clinical settings.
Additional resource use required to deliver the intervention, such as staff-training costs and information or instructional materials. Table 11 shows the summary costs provided in Marshall 2020,²⁶ which assessed the home-based EVA Park virtual reality program. This study also calculated the total per participant cost for the intervention (assuming 16 participants) was £1,364 when including hardware costs and £114 for an average online attendance (excluding hardware).

Table 10

Example costs of computer-based tools for the treatment of aphasia.

Table 11

Summary costs from Marshall 2020.

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

One cost-utility analysis found that in post-stroke adults with aphasia, computerised word-finding therapy was not cost-effective when compared to usual care alone (ICER of £42,686 per QALY gained) or when compared to attention control plus usual care (ICER of £40,164 per QALY gained). This study was assessed as directly applicable with potentially serious limitations.
One cost-utility analysis found that in post-stroke adults with aphasia, computerised word-finding and reading therapy was cost-effective when compared to usual care alone (ICER of £3,058 per QALY gained). This study was assessed as partially applicable with potentially serious limitations.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

The committee included the following outcomes: person/participant generic health-related quality of life, carer generic health-related quality of life, communication outcomes, including: overall language ability, impairment specific measures (such as naming, auditory comprehension, reading, expressive language and speech impairment and activity for people with dysarthria) and functional communication, communication related quality of life, psychological distress (including depression, anxiety and distress) and discontinuation. All outcomes were considered equally important for decision making and therefore have all been rated as critical.

Person/participant health-related quality of life outcomes were considered particularly important as a holistic measure of the impact on the person’s quality of living. However, the committee acknowledged that generic measures may be more responsive to physical changes after stroke and less responsive to communication changes, and this may affect the interpretation of the outcome. In particular, for EQ-5D, the committee noted that there are no subscales specific to communication, which makes it hard to relate to speech and language therapy. In response to this, communication related quality of life scores were also included. Communication outcomes were key to this review as a direct answer to the question. Psychological distress was included as a response to the significant psychological distress that can be experienced by people with communication difficulties that may be resolved by the treatment. Discontinuation was considered as a measure of adherence to the treatment with the acknowledgement that there are unlikely to be significant adverse events as a result of the treatment. Mortality was not considered as it was deemed unlikely to be a result of the treatment. However, if mortality was a reason for discontinuation, then this was highlighted to the committee during their deliberation.

The committee chose to investigate these outcomes at less than 3 months and more than and equal to 3 months, as they considered that there could be a difference in the short term and long term effects of the interventions, in particular for people who have had an acute stroke where effects at less than 3 months could be very different then effects at greater than 3 months. With regards to communication difficulties, this may be seen at 3 months, in contrast to other reviews for this guideline where 6 months was used.

The evidence for this question was limited, with some outcomes not being reported. No study investigated the effects of interventions on carer generic health-related quality of life and the anxiety and distress sections of psychological distress. Outcomes were reported at both less than 3 months and more than and equal to 3 months.

1.1.12.2. The quality of the evidence

Twenty randomised controlled trial studies (including 1 cross-over trial and three quasi-randomised trials) were included in the review. The 3 quasi-randomised trials were included due to the limited evidence investigating computer-based tools for speech and language therapy. However, the limitations produced by the study design was reflected in the risk of bias assessment. Non-randomised studies were considered for this review. However, none were identified that fulfilled the protocol criteria.

The quality of the evidence ranged from high to very low quality, most of the evidence being of low quality. Outcomes were commonly downgraded due to risk of bias (mainly due to bias arising from the randomisation process, bias due to deviations from the intended intervention and bias due to missing outcome data) and imprecision. No outcomes were affected by indirectness.

Some outcomes were downgraded for inconsistency. However, this was less common as meta-analysis was not possible for the majority of outcomes, with only 1 study being included in most outcomes. Where heterogeneity was identified, subgroup and sensitivity analyses did not resolve this mainly due to the limited number of studies making it not possible to form valid subgroups. In general, the majority of studies included people with aphasia, with a minority including people with dysarthria, people with apraxia of speech and a combination of people with other communication difficulties and aphasia. The majority of studies included people in the chronic phase after stroke, with only occasional studies including people in the subacute phase. The types of computer-based tools used varied across the studies, with the majority including a combination of approaches. There was a mixture of therapies being delivered in person and being delivered remotely. The amount of therapy varied between studies ranging from less than and equal to 10 hours to more than and equal to 30 hours.

The majority of the studies included a small number of participants (the majority including 10 to 20 participants in each study arm), while few studies included a larger number of participants (at most around 100 participants in each study arm).

These factors introduced additional uncertainty in the results. The effects on risk of bias did not appear to influence the direction of the effect in the trials. The committee took all these factors into account when interpreting the evidence.

The committee concluded that the evidence was of sufficient quality to make recommendations. They acknowledged the varied quality of the evidence and the heterogeneity in the interventions being compared in this analysis. They committee noted the study size and variations that may occur from studies conducted outside of an NHS-based healthcare setting. However, a large multi-site NIHR funded study³⁷ recently took place in the United Kingdom which included a health economic analysis. The study reported the use of a word finding computer-based therapy compared to social support/stimulation and speech and language therapy without computer-based tools. The study reported many of the outcomes included in this review and was of low risk of bias. Therefore, the committee gave this study greater consideration in their decision making.

1.1.12.2.1. Computer-based tools compared to speech and language therapy without computer-based tools

The majority of identified evidence was considered to be categorised in this comparison. When compared to speech and language therapy without computer-based tools, 39 outcomes were reported that ranged between high and very low quality. Where downgraded, outcomes were commonly downgraded due to risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviations from the intended intervention, bias due to missing outcome data and bias in measurement of the outcome) and imprecision. Two outcomes were downgraded for inconsistency due to the outcomes including a mixture of studies reporting zero events in at least 1 study arm and studies reporting events in both study arms.

1.1.12.2.2. Computer-based tools compared to social support/stimulation

When compared to social support/stimulation, 7 outcomes were reported that ranged from high to very low quality. When downgraded, outcomes were commonly downgraded due to risk of bias (due to bias arising from the randomisation process) and imprecision. Two outcomes were downgraded for inconsistency either as heterogeneity was observed and not resolved by sensitivity analysis or subgroup analysis or that the outcome included a mixture of studies reporting zero events in at least 1 study arm and studies reporting events in both study arms.

1.1.12.2.3. Computer-based tools compared to no treatment

When compared to no treatment, 11 outcomes were reported that ranged from low to very low quality, with the majority being of very low quality. Outcomes were commonly downgraded due to risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in measurement of the outcome) and imprecision. Two outcomes were downgraded for inconsistency as heterogeneity was observed and not resolved by sensitivity analysis or subgroup analysis.

1.1.12.2.4. Computer-based tools compared to placebo

When compared to placebo, 5 outcomes were reported that ranged from low to very low quality, with the majority being of very low quality. Outcomes were commonly downgraded due to risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in measurement of the outcome) and imprecision. One outcome was downgraded for inconsistency either as heterogeneity was observed and not resolved by sensitivity analysis or subgroup analysis.

1.1.12.3. Benefits and harms

1.1.12.3.1. Key uncertainties

The committee agreed that there was significant heterogeneity in the interventions included in the analysis, reflecting the complexity and range of speech and language therapy needs that can be targeted by computerised therapy. The interventions varied from computer programs aiming to deliver speech and language therapy to telerehabilitation approaches aiming to support speech and language therapist to deliver therapy over long distances. A subgroup analysis for remote delivery compared to in person delivery of therapy did not resolve any heterogeneity in the analysis. Furthermore, the types of computer programs used to deliver therapy varied significantly. While some focussed on specific methods of therapy (for example: word finding therapy) others included a mixture of approaches aiming for more holistic delivery of therapy. A subgroup analysis for the method of therapy did not resolve any heterogeneity in the analysis.

The comparisons included varied within groups. For the computer-based tools compared to speech and language therapy without computer-based tools comparison, comparisons could be split into two categories:

Speech and language therapy with computer-based tools compared to equal amounts of therapy without computer-based tools (intensity and duration matched)
Speech and language therapy with computer-based tools in addition to speech and language therapy delivered in person compared to in person delivery only (usual care with additional computer-based tools)

The committee noted that computer-based tools for speech and language therapy would most likely not be used as the only speech and language therapy for a person. Speech and language therapy with computer-based tools can often allow for training in activities where repetition is required, but it is often harder to adapt to the person’s needs. The approach can make it harder for the person after stroke to feel they are receiving adequate attention if it is not adequately supported by a health care professional or is not person centred, and this may reduce their motivation to continue with the computer therapy. The committee noted that personalisation was possible with some computer software, but this will incur additional costs for staff to be involved with this process (including additional time with people to discuss how the therapy is going). The approaches used in the studies varied.

The committee noted that the evidence included mostly small studies with very few participants and so it was difficult to make firm conclusions about the efficacy of the intervention. The majority of interventions appeared to include components of word finding, but there were very few interventions looking at other methods of therapy. In addition, the majority of evidence was for people with aphasia with very few studies involving people with other types of speech and language difficulties (such as dysarthria and apraxia of speech). The committee agreed that additional research with larger sample sizes, computerised therapy focussed on other aspects of speech and language impairment, and ways to support use of new speech and language skills in everyday communication situations would be important for future work.

1.1.12.3.2. Computer-based tools compared to speech and language therapy without computer-based tools, social support/stimulation, no treatment and placebo

When compared to speech and language therapy without computer-based tools, clinically important benefits were seen for psychological distress – depression and discontinuation at less than 3 months and more than and equal to 3 months. Unclear effects where some outcomes indicated a clinically important benefit of computer-based tools, while others indicated no clinically important difference was seen for naming at less than 3 months and more than and equal to 3 months and expressive language at more than and equal to 3 months. An unclear effect where some outcomes indicated a clinically important benefit of computer-based tools (including 30 participants), while others indicated a clinically important benefit of speech and language therapy without computer-based tools (including 198 participants) was seen for person/participant generic health-related quality of life at more than and equal to 3 months. No clinically important difference was seen for overall language ability, reading functional communication and communication related quality of life at less than 3 months and more than and equal to 3 months and auditory comprehension, expressive language, speech impairment – dysarthria and activity – dysarthria at less than 3 months. An unclear effect where some outcomes indicated no clinically important difference, while others indicated a clinically important benefit of speech and language therapy without computer-based tools was seen for auditory comprehension at more than and equal to 3 months.

When compared to social support/stimulation, clinically important benefits were seen for naming at less than 3 months and more than and equal to 3 months. No clinically important difference was seen in person/participant generic health-related quality of life, functional communication and communication related quality of life at more than and equal to 3 months and discontinuation at less than 3 months and more than and equal to 3 months. When compared to no treatment, clinically important benefits were seen for naming and communicated related quality of life at less than 3 months. No clinically important difference was seen in overall language ability, auditory comprehension, expressive language, functional communication, depression and discontinuation at less than 3 months. When compared to placebo, no clinically important difference was seen for overall language ability at less than 3 months and more than and equal to 3 months and naming at less than 3 months. Clinically important harms of computer-based tools were seen in discontinuation at less than 3 months and more than and equal to 3 months.

The committee noted that the evidence was complicated to examine due to the variety of computer-based tools being meta-analysed that were examining different techniques. The intervention of note had a high degree of interventional complexity that made it complicated to fully understand using this analysis. However, the committee weighed up the benefits and the harms from the evidence available. Benefits were seen in naming therapies that were either focussed on word finding or included word finding as a component. The committee noted that this was realistic but highlighted that this did not necessarily make a difference on a person’s ability to communicate. They noted that word finding may be useful for finding specific words, but not necessarily to use those words in communication and required extra support to put those words into context. No clinically important differences were seen in functional communication, which may indicate that the ability to use words in context may not have been achieved with these therapies.

The committee noted that the outcome reported for person/participant generic health-related quality of life was EQ-5D, that did not specifically include a subscale for communication. Due to this, it is difficult to conclude that the interventions are or are not effective based on this outcome. Therefore, the committee did not give the outcome a large weighting in their decision when making recommendations.

The committee considered the clinically important harm in discontinuation when computer-based tools were compared to placebo. People dropped out for unclear reasons during the first 2 weeks of therapy in 1 study in the group using computer-based tools, which may reflect dissatisfaction with the computer-based therapy though this is uncertain. Weighing up this evidence against the potential evidence of benefits, the committee decided that the evidence of benefit outweighed the potential for harm from this. If people found that computer-based tools were not suitable for them then they could work with their therapist to explore other methods of therapy, including methods that do not use computer-based tools.

The committee agreed that computer-based tools for speech and language therapy should be used as an adjunct to speech and language therapy, not alone. There was insufficient evidence of clinically important changes in anything except in improving word finding. Most of the evidence was from small studies and it was not possible to make recommendations, either positive or negative, for other uses of computer-based speech and language tools. Based on this they agreed that computer-based tools could be considered where word finding is an important aim for the person after stroke and they should be used as an adjunct to therapy delivered by a speech and language therapist. However, there should also be additional research with larger sample sizes investigating the other potential uses of computer-based tools for speech and language therapy to gain a complete understanding of the effect of the interventions.

1.1.12.4. Cost effectiveness and resource use

The economic evidence review included 2 published studies with relevant comparisons. These studies were economic evaluations of a pilot feasibility trial (CACTUS) and a randomised controlled trial (Big CACTUS) of the StepByStep computer program, respectively - both of which were included in the clinical review. The StepByStep software allowed for participants to receive supported self-managed intensive speech practice at home. Both studies were UK model-based cost-utility analyses with lifetime horizons, although the interventions differed slightly as described in the following paragraphs.

The CACTUS trial compared the StepByStep approach (computer exercises, support from an SLT and a volunteer who practiced carryover activities face to face) to usual stimulation, which included activities that provided general language stimulation, such as communication support groups and conversation, as well as reading and writing activities. The analysis included a three-state Markov model with month-long cycles, whereby participants could transition from their initial aphasia health state to a response state (defined as a ≥17% increase in proportion of words named correctly at 5 months), or to death. Patients in the response state could relapse to the aphasia state or die. Utility weights were assigned to response and no response states to estimate QALYs, which were measured using a pictorial version of EQ-5D-3L (adapted for this study to be accessible to patients with aphasia) collected at baseline and at 5-and 8-months. 5-month utility data was then extrapolated to a lifetime horizon with 0.08% monthly relapse rate applied. Intervention costs included computers and microphones provided to participants, as well StepByStep software and training for speech and language therapists (SLTs). Healthcare resource use between both groups was also compared using patient and carer diaries collected at 5 months post-randomisation. After 5 months, resource use costs were assumed to be the same for both groups by applying 5-month resource use estimates collected from the control group. The results of the CACTUS trial suggested that StepByStep was cost-effective, with an incremental cost of only £437 for an incremental QALY gain of 0.14, producing an incremental cost-effectiveness ratio (ICER) of £3,058 per QALY gained. Probabilistic sensitivity analyses also suggested that the probability of the intervention being cost-effective was 75.8% at a £20,000 threshold. However, deterministic sensitivity analyses found that the base case results were sensitive to utility gain (for example, utility gain of ≤0.01 resulted in ICER of >£20,000) and relapse rate parameters (for example, relapse rate of >30% resulted in ICER of >£20,000).

This study was assessed as partially applicable for this review, as 2010-unit costs may not reflect the current UK NHS context and the year in which resource use estimates were collected was not reported. Potentially serious limitations were also identified, as the lifetime model was based on an RCT with a short follow up (8 months) and focused on one piece of software which limits interpretation for the wider evidence base identified in the clinical review. Additional limitations included: resource use estimates were taken from a self-reported questionnaire not from a systematic review; utility of non-responders assumed to be equal for both trial groups, overlooking the possibility that non-responder utility scores could be lower in the intervention group; the definition of a “good response” was arbitrarily defined, and how the accessible version of the EQ-5D-3L questionnaire is yet to be validated, although this did allow for utility scores to be elicited directly from people with aphasia. Finally, it should be noted that the sample size of the CACTUS trial was small (n=34) and aimed to assess the feasibility of a rigorous RCT of a self-managed computer therapy. Therefore, it cannot be expected to provide conclusive cost-effectiveness results.

For this reason, an economic evaluation of Big CACTUS trial was conducted. The trial compared the StepByStep program to both usual care and an attention control arm, who received puzzle books and monthly supportive telephone calls plus usual care. The StepByStep intervention was delivered both remote and in-person, supported by volunteers and SLT assistants. The Markov model included with 3-month cycles where all participants begin in the ‘aphasia’ health state but differed from the model used in the CACTUS trial, as it included two tunnel heath states for ‘good response’ (defined as a ≥10% increase in words correctly found on a naming test and/or a 0.5 increase on the Therapy Outcomes Measures activity scale) at 6 and 9 months from baseline. No new responses were assumed to occur after 12 months – participants either remained in the ‘good response (12 months and beyond), relapsed to the ‘Aphasia’ health state or die. People in the ‘Aphasia’ health state at 12 months either remain in that health state or die. Utility weights were assigned to response and no response states to estimate QALYs, which were measured using an adapted pictorial version of EQ-5D-5L collected at baseline, 6, 9 and 12 months. EQ-5D-5L scores were also mapped to EQ-5D-5L using an algorithm by Van Hout 2012⁴⁴. The relapse rate observed between 9 and 12 months was assumed to remain constant for the remainder of the modelled period, hence it was assumed that good responses were lost over time. Only intervention costs were incorporated into the model, which included hardware and software costs (computers, including StepByStep software licences, headphones, puzzle books), SLT training costs and volunteer time/travel costs for SLTs and SLT assistants.

The results found that StepByStep was not cost-effective when compared to usual care, as the QALY gain associated with the intervention was small (0.017) relative to the incremental cost (£733), resulting in an ICER of £42,686 per QALY gained. The same result was found when the intervention was compared to the active control group (£40,165 per QALY gained). The active control group was also dominated by usual care, having higher costs (£695) and lower QALYs (−0.0001). The probability that usual care was cost-effective was 56% at a £20,000 threshold, compared to 22% for both the active control and StepByStep groups. The only cost-effective result identified for the StepByStep intervention was when only patient subgroups with moderate word finding difficulties were assessed, which reported an ICER of £13,673 per QALY gained when compared to the active control group, and £21,262 per QALY gained for StepByStep compared to usual care alone. Alternative costing assumptions (including the inclusion of volunteer costs) did not change conclusions on cost-effectiveness. The study was deemed as directly applicable with potentially serious limitations for the following reasons: This lifetime model was based on an RCT with a short follow up (12 months) and assessed a single piece of software; the health-related quality of life benefit of a “good response” for the StepByStep intervention was small and uncertain; only direct intervention costs were included as Big CACTUS did not collect data on wider resource use (due to the CACTUS pilot study reporting no important differences in indirect resource use) and the how the accessible version of the EQ-5D-5L questionnaire is yet to be validated.

In addition to the economic evidence, unit costs of computer-based tools and health care professionals that were reported in the clinical studies were presented to aid committee discussion. Additional resource use would be required for computer-based therapy, and variation in resource use across studies reported in the clinical review highlighted the uncertainty towards the potential resource impact of these interventions on the NHS. For example, the cost per patient for these tools depends on both the type of software and whether multiple licences are purchased at once. The intervention setting would also affect the resource impact, as the clinical studies reported interventions that were conducted in hospitals, community centres, and outpatient rehabilitation centres, as well as those that were delivered remotely. Non-clinical settings will incur lower or no costs compared to clinical settings, while remote-based therapies are considered to be less resource intensive compared to face-to-face therapy. Differences in the frequency and duration of therapy delivery were also reported, with sessions ranging from 20-90 minutes, occurring 2-6 days per week, for a total of 4-13 weeks. Staff who delivered the intervention varied as studies reported using physiotherapists, occupational therapists, or trained instructors. The Big CACTUS RCT also reported the use of SLTs and SLT assistants as well as trained volunteers to deliver the intervention. Studies also reported other various resource use requirements, such as staff-training costs and information or instructional materials.

The committee discussed economic evidence, noting that the results of the two included studies could not be used to reflect the cost-effectiveness of the wider evidence base as they assessed a single computer program that required substantial resource use in terms of hardware and software costs compared to other interventions identified in the clinical review. Neither version of the StepByStep program is widely available as part of current practice which would increase the resource impact if recommended. Further uncertainty of the cost-effectiveness was raised when considering the variation in the delivery and resource use requirements of the interventions reported in the clinical studies. The committee agreed that there would be a resource impact for providing computer-based therapy as this is not routinely used in current practice.

Although the clinical studies varied in quality, with significant uncertainty due to the complexity of the interventions, clinically important benefits were seen for naming when interventions focused on or included word finding as a component. This led the committee to agree that computer-based interventions aimed at improving naming skills may be useful as additional therapy, as the majority of studies provided computer-based therapy in addition to face-to-face speech and language therapy. The committee also specified that such interventions should be adapted to the needs of the person (for example, word finding activities that include terms which are important to the user). Considering the uncertainty of the clinical evidence and limited economic evidence, the committee proposed a ‘consider’ recommendation for computer-based therapy programmes tailored to individual goals in relation to naming in addition to face-to-face speech and language therapy.

1.1.12.5. Other factors the committee took into account

The committee noted the potential inequity of using programs that are only available in English and notes that there will be some people who cannot access this due to speaking other languages. They noted the complexities for multilingual people who may have therapy focussed on their use of English instead of including all languages that a person may speak. Computer-based tools may exacerbate this inequity in care and so the committee highlighted that it is important to consider all languages that a person speaks and providing holistic support for the person.

The committee noted that computer-based tools may not be accessible for all people, dependent on multiple factors including their access to technology due to cost and computer literacy. Hospitals may be able to lend out technology and provide additional support to people to use it, but it was noted that there may be a geographic variation in the effect of this with a greater requirement for technology to be leant out in areas where there is greater socioeconomic deprivation.

The committee agreed that computer-based tools should not be used as the only speech and language therapy someone should be offered, and that all people who require speech and language therapy should receive support from a speech and language therapist. However, there is currently insufficient available speech therapist time in many Stroke Units, and computer-based tools could be an important means of increasing the intensity of therapy someone could receive (see Evidence review E).

The committee noted that there could be wider effect on psychological outcomes. Some outcomes for evidence were not available for this review, such as outcomes on psychological distress for group-based computer-based tools. The committee discussed how this may help with psychological wellbeing by integrating with other people after stroke.

1.1.13. Recommendations supported by this evidence review

This evidence review supports recommendation 1.12.8 and the research recommendation on computer-based speech and language therapy.

1.1.14. References

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Appendices

Appendix I. Health economic model

Modelling was not prioritised for this question.

Appendix J. Excluded studies

Clinical studies

Table 19

Studies excluded from the clinical review.

Health Economic studies

Download PDF (159K)

Appendix K. Research recommendations – full details

K.1. Research recommendation (PDF, 202K)

Final

Evidence reviews underpinning recommendation 1.12.8 and research recommendations in the NICE guideline

These evidence reviews were developed by NICE

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK600503PMID: 38377263

Table 1PICO characteristics of review question

Population	Inclusion: Adults (age ≥16 years) who have had a first or recurrent stroke (including people after subarachnoid haemorrhage) who have communication difficulties Exclusion: Children (age <16 years) People who had a transient ischaemic attack
Intervention	Computer-based tools for speech and language therapy (to deliver therapy)
Comparisons	Speech and language therapy without computer-based tools (usual care) Social support/stimulation No treatment Placebo Confounding factors (for non-randomised studies only): Severity of the communication disorder Length of time post stroke Age
Outcomes	All outcomes are considered equally important for decision making and therefore have all been rated as critical: At time period: <3 months ≥3 months Person/participant generic health-related quality of life (continuous outcomes will be prioritised [validated measures]) Carer generic health-related quality of life (continuous outcomes will be prioritised [validated measures]) Communication (continuous outcomes will be prioritised) Overall language ability Impairment specific measures – Naming – Auditory comprehension – Reading – Expressive language – Speech impairment (dysarthria) – Activity (dysarthria) Functional communication Communication related quality of life (continuous outcomes will be prioritised) Psychological distress (continuous outcomes and aphasia specific measurement tools will be prioritised) Depression Anxiety Distress Discontinuation (dichotomous outcome)
Study design	Systematic reviews of RCTs Parallel RCTs Cluster randomised trials Crossover studies (for people after chronic stroke only) Non-randomised studies (if insufficient RCT evidence is available) Prospective cohort studies Retrospective cohort studies

Table 2Summary of studies included in the evidence review

Study

Intervention and comparison

Population

Outcomes

Comments

Braley 2021⁴

Computer-based tools for speech and language therapy (n=17)

Computer-based tools for speech and language therapy (Constant Therapy app) for at least 30 minutes a day and at least 5 days a week.

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Word finding therapy

Speech and language therapy without computer-based tools (usual care) (n=15)

A regime of standard, paper workbooks used for homework practice: at least 1 exercise within the workbook at least 5 days a week.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 61.4 (10.3) years

N = 32

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Overall language ability at ≥3 months

Communication related quality of life at ≥3 months

Setting: Home-based in the United States of America and Canada.

Funding: Funded by The Learning Corp. The Learning Corp is now called Constant Therapy Health.

Caute 2019⁶

Computer-based tools for speech and language therapy (n=11)

Computer based tools for speech and language therapy (Claro Software). 1-2 hours of technology set-up training, immediately followed by 12 one-hour therapy sessions delivered over 6 weeks (2 sessions per week).

Total number of hours of therapy delivered using computer tools: 11-20 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Reading therapy

No treatment

(n=10)

Waiting list control.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 55.8 (12.2) years

N = 23

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥ 6 months)

Communication – Impairment specific measures (reading) at <3 months

Functional communication at <3 months

Communication related quality of life at <3 months

Psychological distress – depression at <3 months

Discontinuation at <3 months

Setting: Most people were treated in a University clinic, two were treated in their own home and one at a community centre in the United Kingdom.

Funding: funded by The Barts Charity, Grantcode: MGU0243 awarded to Jane MArshall and Celia Woolf.

Cherney 2010⁷

Computer-based tools for speech and language therapy (n=11)

ORLA treatment in the aphasia clinic, scheduled 2 to 3 times a week.

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Word finding therapy

Speech and language therapy without computer-based tools (usual care) (n=14)

Same therapy delivered by a therapist instead.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 59.1 (12.8) years

N = 25

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥ 6 months)

Communication – Overall language ability at ≥3 months

Communication – Impairment specific measures (reading) at ≥3 months

Setting: Outpatient follow up in the United States of America.

Funding: Supported by grants H133G060055 and H133G010098from the National Institute on Disability and Rehabilitation Research, US Department of Education.

Cherney 2021⁸

Computer-based tools for speech and language therapy (n=22)

Web based ORLA (Oral Reading for Language in Aphasia). Practice 90 minutes/day, six days/week for six weeks.

Concomitant therapy: No additional information.

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Reading therapy

Placebo (n=13)

Commercially available computer game.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): intervention: 58.27(13.55), control: 55.19(11.46) years

N = 35

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Overall language ability at <3 months and ≥3 months

Discontinuation at <3 months and ≥3 months

Setting: Free-standing urban rehabilitation hospital in the United States of America.

Funding: Grant H133G06055 from the National Institute on Disability, Independent Living, and Rehabilitation Research.

De Luca 2018¹¹

Computer-based tools for speech and language therapy (n=17)

Power-Afa training 24 sessions of 45 minutes each,3 times a week for 8 weeks.

Total number of hours of therapy delivered using computer tools: 11-20 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=15)

Traditional training only.

Concomitant therapy:

Traditional training available to all (standard cognitive rehabilitation for language disorders that was founded on cognitive neuropsychological approach to aphasia). 3 training sessions per week for 8 weeks (24 sessions of 45 minutes each).

People after a first or recurrent stroke

Mean age (SD): 51.7 (14.8) years

N = 32

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Psychological distress – depression at <3 months and ≥3 months

Setting: Outpatient follow up in Italy.

Funding: No additional information.

Elhakeem 2021¹³

Computer-based tools for speech and language therapy (n=25)

The software Rawag (Arabic software program) was delivered in therapy sessions with 2 sessions per week for 60 minutes a session with a total of 48 sessions over 6 months.

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=25)

Conventional therapy provided for 2 sessions per week for 60 minutes with a total of 48 sessions over 6 months.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 57.9 (11.3) years

N = 50

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Majority Chronic (around 90%)

Communication – Overall language ability at ≥3 months

Communication – Impairment specific measures (naming) at ≥3 months

Communication – Impairment specific measures (reading) at ≥3 months

Communication – Impairment specific measures (auditory comprehension) at ≥3 months

Communication – Impairment specific measures (expressive language) at ≥3 months

Discontinuation at ≥3 months

Setting: Outpatient follow up (in the Phoniatrics unit) in Egypt.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Fleming 2020¹⁴

Computer-based tools for speech and language therapy (n=37)

Listen-In daily self-managed spoken word comprehension therapy using a computer tablet with a target dose of 100 hours (80 minutes per day) delivered over 12 weeks.

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Comprehension therapy

No treatment

(n=37)

Standard care where people continued their usual daily activities for 12 weeks.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD):

N = 37

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Overall language ability at ≥3 months

Communication – Impairment specific measures (auditory comprehension) at ≥3 months

Discontinuation at ≥3 months

Crossover trial.

Setting: Home-based in the United Kingdom.

Funding: Funded by the NIHR.

Katz 1991¹⁹

Computer-based tools for speech and language therapy (n=10)

Computer reading treatment. The computer reading treatment group used computers 3 hours each week to run visual-matching and reading comprehension software.

Treatment was for 13 weeks (39 hours in total).

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Word finding therapy

No treatment

(n=5)

Received no computer reading treatment or stimulation

Placebo (n=7)

Computer stimulation. 3 hours computer use per week using cognitive rehabilitation software and computerized arcade-type games that did not include language stimuli.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 62.8 (6.6) years

N = 23

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Overall language ability at ≥3 months

Setting: Outpatient follow up in the United States of America.

Funding: supported in part by the Department of Veterans Affairs Rehabilitation Research and Development, Department of Medicine and Surgery.

Kesav 2017²⁰

Computer-based tools for speech and language therapy (n=12)

12 hours of addition supervised computer- based language rehabilitation therapy for 1 hour per session being delivered three times a week for 4 weeks.

Total number of hours of therapy delivered using computer tools: 11-20 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=12)

Conventional therapy only themed on the same premises only.

Concomitant therapy:

Speech and language therapist mediated conventional therapy for 12 hours with 1- hour sessions being delivered three times a week for 4 weeks.

People after a first or recurrent stroke

Mean age (SD): 52.5 (12.3) years

N = 24

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Subacute (7 days - 6 months)

Communication – Overall language ability at <3 months and ≥3 months

Discontinuation at <3 months and ≥3 months

Setting: Tertiary health care institution outpatient follow-up in India.

Funding: Centre for Disability Studies, Government of India (CeDS/FA/2011-2012).

Liu 2021²³

Computer-based tools for speech and language therapy (n=35)

30 minutes of speech and language therapy combined with computer-assisted executive control training for 30 minutes once a day, 6 days a week for up to 4 weeks.

Total number of hours of therapy delivered using computer tools: 11-20 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Other cognitive therapy

Speech and language therapy without computer-based tools (usual care) (n=35)

Speech and language therapy for 4 weeks.

Routine language training for 30 minutes two times a day, 6 days a week for a total of 4 weeks.

Concomitant therapy:

Speech and language therapy was focused on training-specific deficits with corresponding training modules that covered auditory comprehension, repetition, reading, naming and writing.

People after a first or recurrent stroke

Mean age (SD): 52.9 (14.1) years

N = 70

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Subacute (7 days - 6 months)

Communication – Overall language ability at <3 months

Communication – Impairment specific measures (naming) at <3 months

Communication – Impairment specific measures (auditory comprehension) at <3 months

Communication – Impairment specific measures (expressive language) at <3 months

Discontinuation at <3 months

Setting: Outpatient follow up in China.

Funding: The National Science Foundation of China (31871133), National Key Research and Development Programs (2020YFC2006604), and Xuzhou Science and Technology Project (KC17177).

Maresca 2019²⁴

Computer-based tools for speech and language therapy (n=15)

Virtual reality rehabilitation system-tablet 5 days a week with each session lasting about 50 minutes.

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=15)

Traditional linguistic treatment with the same exercises as the experimental linguistic therapy. The study lasted 6 months and included the two phases which lasted 12 weeks each. Training was completed 5 days a week with each session lasting about 50 minutes.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 51.3 (11.6) years

N = 30

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Not stated/unclear

Person/participant generic health-related quality of life at ≥3 months

Communication – Impairment specific measures (auditory comprehension) at ≥3 months

Psychological distress – depression at ≥3 months

Setting: Initially inpatient in Italy.

Funding: No additional information.

Marshall 2016²⁵

Computer-based tools for speech and language therapy (n=10)

EVA Park intervention. Daily sessions with a support worker (25 sessions in total) each lasting about one hour, supplemented by unlimited independent access. Duration 7 weeks.

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Combinations of the above

No treatment

(n=10)

Waitlist control group.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 57.8 (11.9) years

N = 20

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Impairment specific measures (naming) at <3 months

Functional communication at <3 months

Discontinuation at <3 months

Setting: Data were collected in the participants’ homes or at City University London in the United Kingdom.

Funding: No additional information.

Marshall 2020²⁶

Computer-based tools for speech and language therapy (n=16)

EVA Park virtual reality group discussion sessions delivered as one and a half hour sessions with 14 sessions over 6 months.

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Expressive language/communication

No treatment

(n=18)

Delayed treatment (treatment given after 6 months).

Concomitant therapy: Usual care (not defined).

People after a first or recurrent stroke

Median age (IQR):

Computer-based tools: 51 (46.5-57.5) years

No treatment: 65 (51.5-71.25) years

N = 34

Type of communication difficulty: Aphasia.

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Overall language ability at ≥3 months

Communication - Functional communication at ≥3 months

Communication related quality of life at ≥3 months

Discontinuation at ≥3 months

Setting: Home-based (virtual reality) in the United Kingdom.

Funding: Funded by The Stroke Association.

Meltzer 2018²⁷

Computer-based tools for speech and language therapy (n=22)

Weekly 1-hour sessions with the therapist over 10 weeks received in telerehabilitation conditions.

Total number of hours of therapy delivered using computer tools: ≤10 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=22)

Same therapy principles but delivered in person.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 64.2 (11.1) years

N = 44

Type of communication difficulty: Mixed.

Aphasia or cognitive communication

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Impairment specific measures (naming) at <3 months

Communication – Impairment specific measures (auditory comprehension) at <3 months

Communication – Impairment specific measures (expressive language) at <3 months

Setting: Outpatient setting in Canada.

Funding: The project was supported by a “Telerehabilitation for Stroke” grant from the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery. Matching funds were generously provided by the Manitoba Patient Access Network (MPAN).

Mitchell 2018²⁸

Subsidiary study:

Mitchell 2018²⁹

Computer-based tools for speech and language therapy (n=26)

ReaDySpeech, an online computer programme-expected to be over 8 to 10 weeks, although there was no specified intensity or duration.

Total number of hours of therapy delivered using computer tools: Mixed. Intensity and duration could be varied.

Remote delivery/in person delivery: Remote delivery

Method of therapy: Articulation therapy

Speech and language therapy without computer-based tools (usual care) (n=14)

Usual care which would vary by site, from no intervention to best practice guidelines.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (range): Intervention: 70 (37 to 99) years.

Control: 67 (55 to 85) years

N = 40

Type of communication difficulty: Dysarthria

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Subacute (7 days - 6 months)

Communication – Impairment specific measures (speech impairment – dysarthria) at <3 months

Communication – Impairment specific measures (activity – dysarthria) at <3 months

Communication related quality of life at <3 months

Discontinuation at <3 months

Setting: Hospital and community-based stroke services in the United Kingdom.

Funding: funded by the NIHR Doctoral Training Program (project no. DRF-2014-07-043).

Ora 2020³³

Subsidiary study:

Ora 2018³⁴

Computer-based tools for speech and language therapy (n=32)

16 sessions of speech-language therapy via videoconference over 32 days. Average 18.6 (1.5) hours.

Total number of hours of therapy delivered using computer tools: 11-20 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=30)

Usual care only.

AND/OR

Concomitant therapy:

All people received usual care from local speech-language pathologists at the community level and/or in a rehabilitation institution. The dosage was measured by hours from inclusion to follow-up assessment. On average usual care was completed for 20.4 (12.0) hours and 25.0 (13.8) hours for the intervention and control group respectively.

People after a first or recurrent stroke

Mean age (SD): 64.9 (12.0) years

N = 62

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Mixed

Communication – Impairment specific measures (naming) at <3 months and ≥3 months

Communication – Impairment specific measures (auditory comprehension) at <3 months and ≥3 months

Discontinuation at <3 months and ≥3 months

Setting: Outpatient follow up in Norway.

Funding: Funded by the South-Eastern Norway Regional Health Authority (project number 2015037) and has also received financial support from the University of Oslo and Sunnaas Rehabilitation Hospital. The NMAHP RU and MB is supported by the Chief Scientist Office, part of the Scottish Government Health and Social Care Directorates.

Palmer 2019³⁷

Subsidiary studies:

Palmer 2015³⁶

Palmer 2020³⁸

Latimer 2021²¹

Computer-based tools for speech and language therapy (n=97)

Daily, self-managed, word-finding exercises on a computer at home, which were tailored to the needs of the individual patient by a speech and language therapist. Duration 6 months.

Total number of hours of therapy delivered using computer tools: Not stated/unclear

Remote delivery/in person delivery: Mixed

Method of therapy: Word finding therapy

Speech and language therapy without computer-based tools (usual care) (n=101)

Usual care only

Social support/stimulation (n=80)

Paper-based puzzle book activities on a daily basis and received supportive telephone calls from the research team once a month.

Concomitant therapy:

All people received usual care. Usual care constituted speech and language therapy amount recorded for 3 months before people who had chronic aphasia longer than 4 months after stroke were randomised.

People after a first or recurrent stroke

Mean age (SD): 65.3 (13.0) years

N = 278

Type of communication difficulty: Mixed.

All had aphasia.

Around 35% had apraxia of speech.

Severity of communication difficulty: Mixed

Time after stroke at the start of the trial: Chronic (≥6 months)

Person/participant generic health-related quality of life at ≥3 months

Communication – Impairment specific measures (naming) at ≥3 months

Functional communication at ≥3 months

Communication related quality of life at ≥3 months

Discontinuation at ≥3 months

Big CACTUS trial.

Setting: Outpatient at speech and language therapy departments in the United Kingdom.

Funding: National Institute for Health Research, Tavistock Trust for Aphasia.

Palmer 2012³⁹

Subsidiary study:

Latimer 2013²²

Computer-based tools for speech and language therapy (n=17)

StepbyStep computer program in addition to usual language activities for at least 20 minutes, 3 days a week for 5 months (approximately 1500 minutes of practice time in total).

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Combinations of the above. Word finding and reading

Speech and language therapy without computer-based tools (usual care) (n=17)

Usual care only.

Concomitant therapy:

All people participated in activities that provide general language stimulation as they had done previously including attendance at communication support groups and conversation, reading and writing activities that were a part of everyday life.

People after a first or recurrent stroke

Mean age (SD): 67.9 (12.4) years

N = 34

Type of communication difficulty: Aphasia but may have also had dyspraxia

Severity of communication difficulty: Mild. Mixed but majority mild

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Impairment specific measures (naming) at ≥3 months

Discontinuation at ≥3 months

CACTUS trial.

Setting: Outpatient follow up in the United Kingdom.

Funding: Independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1207-14097). This study was also supported by the Stroke and Telehealth themes of the South Yorkshire Collaboration for Leadership in applied health research and care (CLAHRC). NIHRCLAHRC) for South Yorkshire acknowledges funding from the National Institute of Health Research. The study also received support from the North of Tyne Primary Care Trust.

Spaccavento 2021⁴²

Computer-based tools for speech and language therapy (n=13)

One, 50 minute session for 5 days per week over a period of 8 weeks.

Total number of hours of therapy delivered using computer tools: ≥30 hours

Remote delivery/in person delivery: In person delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=9)

Therapist-mediated aphasia treatment. One, 50 minute session for 5 days per week over a period of 8 weeks.

Concomitant therapy:

No additional information (all people were provided the same amount of therapy).

People after a first or recurrent stroke

Mean age (SD): 60.1 (12.4) years

N = 22

Type of communication difficulty: Aphasia

Severity of communication difficulty: Mixed.

Moderate to severe

Time after stroke at the start of the trial: Subacute (7 days - 6 months)

Communication – Impairment specific measures (naming) at <3 months

Communication – Impairment specific measures (auditory comprehension) at <3 months

Communication – Impairment specific measures (reading) at <3 months

Communication – Impairment specific measures (expressive language) at <3 months

Functional communication at <3 months

Communication related quality of life at <3 months

Setting: Inpatient in Italy.

Funding: No sponsors. No financial or personal relationships with other people or organisations that could inappropriately influence their work.

Varley 2016⁴⁵

Computer-based tools for speech and language therapy (n=50)

Therapy was delivered for 6 weeks. Regular use of the software was encouraged (once or twice a day for at least 20 minutes).

Total number of hours of therapy delivered using computer tools: ≤10 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Expressive language/communication

Placebo (n=50)

Sham therapy using visuospatial sham program. No speech and language component. Regular use of the software was encouraged (once or twice a day for at least 20 minutes).

Concomitant therapy:

No additional information

People after a first or recurrent stroke

Age range: Intervention: 28 to 91 years

Control: 36 to 86

N = 50 (in the trial in total - 25 in each arm during the randomisation process)

Type of communication difficulty: Apraxia of speech

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Impairment specific measures (naming) at <3 months

Setting: Community speech and language therapy services in the United Kingdom.

Funding: Bupa UK Foundation specialist grant programme.

Washout period of 4 weeks separating the two 6-week treatment periods.

Woolf 2016⁴⁷

Computer-based tools for speech and language therapy (n=10)

Eight sessions of word finding therapy, delivered remotely, twice a week or 4 weeks.

Total number of hours of therapy delivered using computer tools: ≤10 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Word finding therapy

Speech and language therapy without computer-based tools (usual care) (n=5)

Face-to-face sessions of word finding therapy. The same procedure as the computer-based tools group but delivered face to face.

Social support/stimulation (n=5)

Attention control condition where 8 remote conversation sessions were received. Sessions were scheduled twice a week (8 hours in total).

Concomitant therapy:

All people were provided with a workbook, comprising pictures of their target words. Each person worked on 50 words, with each word targeted at least once per session.

People after a first or recurrent stroke

Mean age (SD): 59.2 (13.8) years

N = 20

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Chronic (≥6 months)

Communication – Impairment specific measures (naming) at <3 months and ≥3 months

Discontinuation at <3 months and ≥3 months

Setting: A University lab and NHS outpatient service in the United Kingdom.

Funding: supported by the Tavistock Trust for Aphasia, the Charles Wolfson Charitable Trust and the Bupa Foundation (grant number: TBF-PPW 11-017F).

Zhou 2018⁴⁸

Computer-based tools for speech and language therapy (n=20)

Telerehabilitation training program. The inpatient group received just computerized speech and language therapy while the outpatient group received computerized speech-language therapy for 30 minutes a day in addition to 30 minutes a day of family topics communication for 30. Training was 30 minutes a session, 2 times a day for 30 days.

Total number of hours of therapy delivered using computer tools: 21-30 hours

Remote delivery/in person delivery: Remote delivery

Method of therapy: Combinations of the above

Speech and language therapy without computer-based tools (usual care) (n=20)

The inpatient group received routine therapy twice a day for 30 minutes a session. The outpatient group received family topics communication for 30 minutes a session, 2 times a day for 30 days.

Concomitant therapy:

No additional information.

People after a first or recurrent stroke

Mean age (SD): 57.8 (13.9) years

N = 40

Type of communication difficulty: Aphasia

Severity of communication difficulty: Not stated/unclear

Time after stroke at the start of the trial: Subacute (7 days - 6 months)

Communication – Overall language ability at <3 months

Communication – Impairment specific measures (naming) at <3 months

Communication – Impairment specific measures (auditory comprehension) at <3 months

Functional communication at <3 months

Setting: Inpatients and outpatients in Italy.

Funding: supported by grants from the Natural Science Foundation of China (NSFC 31571156, 31871133) and grants from Jiangsu Province (BRA2017392, 2017-JY-025, H201670 and KYLX16-1302).

Table 3Summary matrix of computer-based tools for speech and language therapy compared to each comparison groups

Outcome	Time point	Computer-based tools compared to speech and language therapy without computer-based tools	Computer-based tools compared to social support/stimulation	Computer-based tools compared to no treatment	Computer-based tools compared to placebo
Person/participant generic health-related quality of life	<3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Person/participant generic health-related quality of life	≥3 months	2 outcomes 2 studies (n=228) Moderate-low quality	No evidence identified.	No evidence identified.
Carer generic health-related quality of life	<3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Carer generic health-related quality of life	≥3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Overall language ability	<3 months	1 outcome 3 studies (n=128) Very low quality	No evidence identified.	1 outcome 1 study (n=15) Low quality	1 outcome 1 study (n=32) Low quality
Communication – Overall language ability	≥3 months	2 outcomes 4 studies (n=127) Low quality	No evidence identified.	No evidence identified.	1 outcome 2 studies (n=46) Very low quality
Communication – Impairment specific measures (naming)	<3 months	2 outcomes 6 studies (n=251) Low-very low quality	1 outcome 1 study (n=15) Low quality	1 outcome 1 study (n=20) Very low quality	1 outcome 1 study (n=100) Low quality
Communication – Impairment specific measures (naming)	≥3 months	3 outcomes 5 studies (n=341) Moderate-low quality	1 outcome 2 studies (n=188) Very low quality	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (auditory comprehension)	<3 months	2 outcomes 5 studies (n=236) High-low quality	No evidence identified.	No evidence identified.	No evidence identified.
	≥3 months	5 outcomes 3 studies (n=142) High-Low quality	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (reading)	<3 months	1 outcome 1 study (n=22) Low quality	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (reading)	≥3 months	3 outcomes 2 studies (n=75) High to very low quality	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (expressive language)	<3 months	2 outcomes 3 studies (n=134) Very low quality	No evidence identified.	1 outcome 1 study (n=31) Very low quality	No evidence identified.
	≥3 months	6 outcomes 1 study (n=50) Moderate quality	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (speech impairment – Dysarthria)	<3 months	1 outcome 1 study (n=37) Very low quality	No evidence identified.	No evidence identified.	No evidence identified.
	≥3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Impairment specific measures (Activity – Dysarthria)	<3 months	1 outcome 1 study (n=37) Very low quality	No evidence identified.	No evidence identified.	No evidence identified.
	≥3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Communication – Functional communication	<3 months	1 outcome 2 studies (n=62) Very low quality	No evidence identified.	1 outcome 2 studies (n=41) Very low quality	No evidence identified.
Communication – Functional communication	≥3 months	1 outcome 1 study (n=191) High quality	1 outcome 1 study (n=173) High quality	No evidence identified.	No evidence identified.
Communication related quality of life	<3 months	1 outcome 2 studies (n=59) Very low quality	No evidence identified.	1 outcome 1 study (n=21) Very low quality	No evidence identified.
Communication related quality of life	≥3 months	1 outcome 2 studies (n=221) High quality	1 outcome 1 study (n=174) High quality	No evidence identified.	No evidence identified.
Psychological distress – depression	<3 months	1 outcome 1 study (n=32) Very low quality	No evidence identified.	1 outcome 1 study (n=21) Very low quality	No evidence identified.
Psychological distress – depression	≥3 months	1 outcome 2 studies (n=62) Moderate quality	No evidence identified.	No evidence identified.	No evidence identified.
Psychological distress – anxiety	<3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Psychological distress – anxiety	≥3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Psychological distress – distress	<3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Psychological distress – distress	≥3 months	No evidence identified.	No evidence identified.	No evidence identified.	No evidence identified.
Discontinuation	<3 months	1 outcome 5 studies (n=211) Very low quality	1 outcome 1 study (n=15) Very low quality	1 outcome 2 studies (n=41) Very low quality	1 outcome 1 study (n=32) Very low quality
Discontinuation	≥3 months	1 outcome 6 studies (n=383) Very low quality	1 outcome 2 studies (n=192) Very low quality	No evidence identified.	1 outcome 1 study (n=32) Very low quality

Table 4Clinical evidence summary: computer-based tools for speech and language therapy compared to speech and language therapy without computer-based tools (usual care)

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with speech and language therapy without computer-based tools (usual care)	Risk difference with Computer-based tools for speech and language therapy	Comments
Person/participant generic health-related quality of life (EuroQol-5D, 0-100, higher values are better, change score) at ≥3 months	30 (1 RCT) follow-up: 6 months	⨁⨁◯◯ Low^a	-	The mean person/participant generic health-related quality of life at ≥3 months was 8.7	MD 13.3 higher (9.23 higher to 17.37 higher)	MID = 3.78 (0.5 x median control group SD)
Person/participant generic health-related quality of life (EQ-5D-5L, −0.11-1, higher values are better, final value) at ≥3 months	198 (1 RCT) follow-up: 12 months	⨁⨁⨁◯ Moderate^b	-	The mean person/participant generic health-related quality of life at ≥3 months was 0.65	MD 0.06 lower (0.13 lower to 0.01 higher)	MID = 0.03 (EQ5D established MID)
Communication - overall language ability (Western Aphasia Battery Aphasia Quotient, 0-100, higher values are better, change score and final values) at <3 months	160 (3 RCTs) follow-up: mean 4 weeks	⨁◯◯◯ Very low^a^,^b^,^c	-	The mean communication - overall language ability at <3 months was 40.9	MD 11.91 higher (7.79 higher to 16.03 higher)	MID = 13.9 (0.5 x median baseline SD)
Communication - overall language ability (Western Aphasia Battery AQ, 0-100, higher values are better, change scores and final value) at ≥3 months	77 (3 RCTs) follow-up: mean 3 months	⨁⨁◯◯ Low^a	-	The mean communication - overall language ability at ≥3 months was 24.7	MD 4.94 higher (2.09 higher to 7.78 higher)	MID = 12.5 (0.5 x median baseline SD)
Communication - overall language ability (Aphasia severity rating scale, 0-5, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁◯◯ Low^b	-	The mean communication - overall language ability at ≥3 months was 2.44	MD 0.04 higher (0.43 lower to 0.51 higher)	MID = 0.34 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (Western Aphasia Battery oral naming, scale range unclear, higher values are better, change score) at <3 months	68 (1 RCT) follow-up: 4 weeks	⨁◯◯◯ Very low^b^,^d	-	The mean communication - impairment specific measures (naming) at <3 months was 0.37	MD 0.89 higher (0.39 lower to 2.17 higher)	MID = 0.87 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (Western Aphasia Battery naming and word finding subscale, NGA subscale naming, AAT naming subtest, naming assessment [different scale ranges], higher values are better, final values) at <3 months	183 (5 RCTs) follow-up: mean 7 weeks	⨁⨁◯◯ Low^a	-	-	SMD 0.12 SD lower (0.41 lower to 0.18 higher)	MID = 0.5 SD (SMD)
Communication - impairment specific measures (naming) (Boston Naming Test, items, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (naming) at ≥3 months was 37.08	MD 9.96 higher (3.75 higher to 16.17 higher)	MID = 3.9 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (words named correctly, word finding ability, %, higher values are better, change scores) at ≥3 months	215 (2 RCTs) follow-up: mean 10 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (naming) at ≥3 months was 8.1	MD 10.82 higher (6.21 higher to 15.42 higher)	MID = 9.3 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (NGA subtest naming, Naming Assessment, 0-100, higher values are better, final values) at ≥3 months	76 (2 RCTs) follow-up: mean 4 months	⨁⨁◯◯ Low^b	-	The mean communication - impairment specific measures (naming) at ≥3 months was 46.8	MD 3.08 lower (13.38 lower to 7.23 higher)	MID = 4.8 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (Western Aphasia Battery auditory comprehension, scale range unclear, higher values are better, change score) at <3 months	68 (1 RCT) follow-up: 4 weeks	⨁⨁◯◯ Low^d	-	The mean communication - impairment specific measures (auditory comprehension) at <3 months was 2.44	MD 0.13 lower (0.66 lower to 0.4 higher)	MID = 1.34 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (Western Aphasia Battery comprehension subtest, NGA comprehension subtest, AAT token subtest [different scale ranges], higher values are better, final values) at <3 months	168 (4 RCTs) follow-up: mean 7 weeks	⨁⨁⨁⨁ High	-	-	SMD 0.02 SD lower (0.33 lower to 0.28 higher)	MID = 0.5 SD (SMD)
Communication - impairment specific measures (auditory comprehension) (Token test, 0-36, higher values are better, change score) at ≥3 months	30 (1 RCT) follow-up: 6 months	⨁⨁◯◯ Low^a	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was −2	MD 5.3 lower (6.94 lower to 3.66 lower)	MID = 1.4 (0.5 x median control group SD)
Communication - impairment specific measures (auditory comprehension) (BDAE complex ideational material subtest, 0-10, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁⨁ High	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 4.4	MD 0.2 higher (1.27 lower to 1.67 higher)	MID = 2.1 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (BDAE commands subtest, 0-24, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁⨁ High	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 4.8	MD 0.08 higher (2 lower to 2.16 higher)	MID = 2.9 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (BDAE basic word discrimination subtest, 0-72, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁⨁ High	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 10.36	MD 0.2 higher (4.72 lower to 5.12 higher)	MID = 6.9 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (NGA subtest comprehension, 0-100, higher values are better, final value) at ≥3 months	62 (1 RCT) follow-up: 4 months	⨁⨁◯◯ Low^b	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 61.5	MD 0.5 lower (13.94 lower to 12.94 higher)	MID = 11.0 (0.5 x median baseline SD)
Communication - impairment specific measures (reading) (Functional Assessment Measure Reading, 0-7, higher values are better, final value) at <3 months	22 (1 RCT) follow-up: 8 weeks	⨁⨁◯◯ Low^b	-	The mean communication - impairment specific measures (reading) at <3 months was 3.78	MD 0.05 higher (1.12 lower to 1.22 higher)	MID = 0.86 (0.5 x median baseline SD)
Communication - impairment specific measures (reading) (Western Aphasia Battery reading, 0-100, higher values are better, change score) at ≥3 months	25 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^b^,^d	-	The mean communication - impairment specific measures (reading) at ≥3 months was 1.36	MD 4.91 lower (15.18 lower to 5.36 higher)	MID = 12.8 (0.5 x median baseline SD)
Communication - impairment specific measures (reading) (BDAE basic oral reading subtest, 0-30, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁⨁ High	-	The mean communication - impairment specific measures (reading) at ≥3 months was 10.21	MD 0.09 higher (3.12 lower to 3.3 higher)	MID = 3.5 (0.5 x median baseline SD)
Communication - impairment specific measures (reading) (BDAE oral reading of sentences with comprehension, 0-10, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁⨁ High	-	The mean communication - impairment specific measures (reading) at ≥3 months was 4.53	MD 0.07 higher (0.98 lower to 1.12 higher)	MID = 1.4 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (Western Aphasia Battery Spontaneous speech, scale range unclear, higher values are better, change score) at <3 months	68 (1 RCT) follow-up: 4 weeks	⨁◯◯◯ Very low^b^,^d	-	The mean communication - impairment specific measures (expressive language) at <3 months was 1.4	MD 1.73 higher (0.48 higher to 2.98 higher)	MID = 2.5 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (Western Aphasia Battery Spontaneous speech, Functional Assessment Measure Expression, [different scale ranges], higher values are better, final values) at <3 months	66 (2 RCTs) follow-up: mean 9 weeks	⨁◯◯◯ Very low^b^,^e	-	-	SMD 0.12 SD lower (0.61 lower to 0.36 higher)	MID = 0.5 SD (SMD)
Communication - impairment specific measures (expressive language) (BDAE articulatory agility subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 1.04	MD 0.2 higher (0.34 lower to 0.74 higher)	MID = 0.67 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (BDAE grammatical forms subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 2.4	MD 0.48 higher (0.13 lower to 1.09 higher)	MID = 0.29 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (BDAE melodic line subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 2.04	MD 1 higher (0.41 higher to 1.59 higher)	MID = 0.48 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (BDAE paraphrasia subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 2.28	MD 1.64 higher (0.46 higher to 2.82 higher)	MID = 1.1 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (BDAE phrase length subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 2.12	MD 0.68 higher (0.12 higher to 1.24 higher)	MID = 0.48 (0.5 x median baseline SD)
Communication - impairment specific measures (expressive language) (BDAE word-finding relative to fluency subtest, 1-7, higher values are better, change score) at ≥3 months	50 (1 RCT) follow-up: 6 months	⨁⨁⨁◯ Moderate^b	-	The mean communication - impairment specific measures (expressive language) at ≥3 months was 0.48	MD 0.8 higher (0 to 1.6 higher)	MID = 0.57 (0.5 x median baseline SD)
Communication - impairment specific measures (dysarthria - speech impairment) (Frenchay Dysarthria Assessment-II, unclear scale range, higher values are better, final value) at <3 months	37 (1 RCT) follow-up: 10 weeks	⨁◯◯◯ Very low^b^,^f	-	The mean communication - impairment specific measures (dysarthria - speech impairment) at <3 months was 184	MD 7 lower (26.05 lower to 12.05 higher)	MID = 15.9 (0.5 x median baseline SD)
Communication - impairment specific measures (dysarthria - activity) (Dysarthria Therapy Outcome Measures, unclear scale range, higher values are better, final value) at <3 months	37 (1 RCT) follow-up: 10 weeks	⨁◯◯◯ Very low^b^,^f	-	The mean communication - impairment specific measures (dysarthria - activity) at <3 months was 3.9	MD 0.3 lower (0.85 lower to 0.25 higher)	MID = 0.48 (0.5 x median baseline SD)
Communication - functional communication (Communication activities of daily living, functional outcome questionnaire aphasia total score [different scale ranges], higher values are better, final values) at <3 months	62 (2 RCTs) follow-up: mean 6 weeks	⨁◯◯◯ Very low^a^,^b	-	-	SMD 0.02 SD lower (0.52 lower to 0.48 higher)	MID = 0.5 SD (SMD)
Communication - functional communication (TOMS, 0-10, higher values are better, change score) at ≥3 months	191 (1 RCT) follow-up: 12 months	⨁⨁⨁⨁ High	-	The mean communication - functional communication at ≥3 months was 0.13	MD 0.01 lower (0.23 lower to 0.21 higher)	MID = 0.55 (0.5 x median baseline SD)
Communication related quality of life (COAST, Quality of Life Questionnaire for Aphasics Total score [different scale ranges], higher values are better, final values) at <3 months	59 (2 RCTs) follow-up: mean 9 weeks	⨁◯◯◯ Very low^b^,^g	-	-	SMD 0.34 SD lower (0.87 lower to 0.18 higher)	MID = 0.5 SD (SMD)
Communication related quality of life (Stroke and Aphasia Quality of Life Scale-39, COAST [different scale ranges], higher values are better, change scores) at ≥3 months	221 (2 RCTs) follow-up: mean 8 months	⨁⨁⨁⨁ High	-	-	SMD 0.09 SD lower (0.35 lower to 0.18 higher)	MID = 0.5 SD (SMD)
Psychological distress - depression (Aphasic Depression Rating Scale, scale range unclear, higher values are better, final value) at <3 months	32 (1 RCT) follow-up: 8 weeks	⨁◯◯◯ Very low^b^,^h	-	The mean psychological distress - depression at <3 months was 0.5	MD 4.9 higher (3.08 higher to 6.72 higher)	MID = 3.2 (0.5 x median baseline SD)
Psychological distress - depression (Aphasic Depression Rating Scale, unclear scale range, higher values are better, change scores) at ≥3 months	62 (2 RCTs) follow-up: mean 6 months	⨁⨁⨁◯ Moderate^b	-	The mean psychological distress - depression at ≥3 months was 1.1	MD 4.54 higher (3.18 higher to 5.89 higher)	MID = 3.2 (0.5 x median baseline SD)
Discontinuation at <3 months	211 (5 RCTs) follow-up: mean 6 weeks	⨁◯◯◯ Very low^a^,^b^,ⁱ	RD 0.06 (−0.09 to 0.20)	63 per 1,000	59 fewer per 1,000 (68 fewer to 50 fewer)^j	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.71 (0.80.9 = serious, <0.8 = very serious).
Discontinuation at ≥3 months	383 (6 RCTs) follow-up: mean 6 months	⨁◯◯◯ Very low^b^,ⁱ	RD 0.01 (−0.06 to 0.09)	158 per 1,000	156 fewer per 1,000 (167 fewer to 144 fewer)^j	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.06 (0.80.9 = serious, <0.8 = very serious).

a: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in measurement of the outcome)

b: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

c: Downgraded by 1 or 2 increments because heterogeneity, unexplained by subgroup analysis

d: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions and bias in measurement of the outcome)

e: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions and bias due to missing outcome data)

f: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias due to deviations from the intended interventions and bias due to missing outcome data)

g: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias due to deviations from the intended interventions and bias due to missing outcome data)

h: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in selection of the reported result)

i: Downgraded for heterogeneity due to conflicting number of events in different studies (zero events in one or more studies)

j: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

Table 5Clinical evidence summary: computer-based tools for speech and language therapy compared to social support/stimulation

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with social support/stimulation	Risk difference with Computer-based tools for speech and language therapy	Comments
Person/participant generic health-related quality of life (EQ-5D-5L, −0.11-1, higher values are better, final value) at ≥3 months	177 (1 RCT) follow-up: 12 months	⨁⨁◯◯ Low^a	-	The mean person/participant generic health-related quality of life at ≥3 months was 0.59	MD 0 (0.07 lower to 0.07 higher)	MID = 0.03 (EQ-5D established MID)
Communication - impairment specific measures (naming) (naming assessment, 0-100, higher values are better, final value) at <3 months	15 (1 RCT) follow-up: 8 weeks	⨁⨁◯◯ Low^b	-	The mean communication - impairment specific measures (naming) at <3 months was 9.6	MD 29 higher (14.38 higher to 43.62 higher)	MID = 4.1 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (word finding ability, naming assessment, 0-100/%, higher values are better, change score and final value) at ≥3 months	188 (2 RCTs) follow-up: mean 8 months	⨁◯◯◯ Very low^a^,^c	-	The mean communication - impairment specific measures (naming) at ≥3 months was 8.75	MD 16.96 higher (2.52 lower to 36.44 higher)	MID = 7.4 (0.5 x median baseline SD)
Communication - functional communication (TOMS, 0-10, higher values are better, change score) at ≥3 months	173 (1 RCT) follow-up: 12 months	⨁⨁⨁⨁ High	-	The mean communication - functional communication at ≥3 months was 0.09	MD 0.03 higher (0.22 lower to 0.28 higher)	MID = 0.55 (0.5 x median baseline SD)
Communication related quality of life (COAST, %, higher values are better, change score) at ≥3 months	173 (1 RCT) follow-up: 12 months	⨁⨁⨁⨁ High	-	The mean communication related quality of life at ≥3 months was 3.4	MD 1.9 higher (2.31 lower to 6.11 higher)	MID = 6.85 (0.5 x median baseline SD)
Discontinuation at <3 months	15 (1 RCT) follow-up: 8 weeks	⨁◯◯◯ Very low^b^,^d	RD 0.00 (−0.25 to 0.25)	0 per 1,000	0 fewer per 1,000 (250 fewer to 250 more)^e	Sample size used to determine precision: 75-150 = serious imprecision, <75 = very serious imprecision.
Discontinuation at ≥3 months	192 (2 RCTs) follow-up: mean 8 months	⨁◯◯◯ Very low^d^,^f	RD 0.03 (−0.08 to 0.15)	200 per 1,000	30 more per 1,000 (80 fewer to 150 more)^e	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.08 (0.8-0.9 = serious, <0.8 = very serious).

a: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

b: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process)

c: Downgraded by 1 or 2 increments because heterogeneity, unexplained by subgroup analysis

d: Downgraded by 1 to 2 increments for imprecision due to zero events and small sample size

e: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

f: Downgraded for heterogeneity due to conflicting number of events in different studies (zero events in one or more studies)

Table 6Clinical evidence summary: computer-based tools for speech and language therapy compared to no treatment

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with no treatment	Risk difference with Computer-based tools for speech and language therapy	Comments
Communication - overall language ability (Western Aphasia Battery AQ, 0-100, higher values are better, change score and final value) at ≥3 months	49 (2 RCTs) follow-up: mean 5 months	⨁◯◯◯ Very low^a^,^b^,^c	-	The mean communication - overall language ability at ≥3 months was 36.6	MD 5.39 higher (1.16 lower to 11.95 higher)	MID = 7.0 (0.5 x median baseline SD)
Communication - overall language ability (comprehensive aphasia test - spoken words, 0-30, higher values are better, final value) at ≥3 months	72 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^c^,^d	-	The mean communication - overall language ability at ≥3 months was 18	MD 2 higher (1.01 lower to 5.01 higher)	MID = 3 (0.5 x median baseline SD)
Communication - overall language ability (comprehensive aphasia test - spoken sentences, 0-30, higher values are better, final value) at ≥3 months	72 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^c^,^d	-	The mean communication - overall language ability at ≥3 months was 10	MD 0 (2.55 lower to 2.55 higher)	MID = 2 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (verbal fluency, items, higher values are better, final value) at <3 months	20 (1 RCT) follow-up: 7 weeks	⨁◯◯◯ Very low^c^,^e	-	The mean communication - impairment specific measures (naming) at <3 months was 62.5	MD 19.5 higher (7.51 lower to 46.51 higher)	MID = 13.1 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (auditory comprehension test - trained items correct, %, higher values are better, final value) at ≥3 months	72 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^c^,^d	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 62	MD 6 higher (2.09 lower to 14.09 higher)	MID = 7.5 (0.5 x median baseline SD)
Communication - impairment specific measures (auditory comprehension) (auditory comprehension test - untrained items correct, %, higher values are better, final value) at ≥3 months	72 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^c^,^d	-	The mean communication - impairment specific measures (auditory comprehension) at ≥3 months was 58	MD 2 lower (9.65 lower to 5.65 higher)	MID = 7 (0.5 x median baseline SD)
Communication - impairment specific measures (reading) (Reading Comprehension Battery for Aphasia subtests 7-9, 0-30, higher values are better, final value) at <3 months	21 (1 RCT) follow-up: 6 weeks	⨁◯◯◯ Very low^c^,^f	-	The mean communication - impairment specific measures (reading) at <3 months was 19.8	MD 0.47 higher (6.05 lower to 6.99 higher)	MID = 4.1 (0.5 x median baseline SD)
Communication - functional communication (Communication Activities of Daily Living [different scale ranges], higher values are better, final values) at <3 months	41 (2 RCTs) follow-up: mean 7 weeks	⨁◯◯◯ Very low^b^,^c^,^d	-	-	SMD 0.12 SD higher (1.12 lower to 1.36 higher)	MID = 0.5 SD (SMD)
Communication - functional communication (Communication Activities of Daily Living, 0-100, higher values are better, final value) at ≥3 months	34 (1 RCT) follow-up: 6 months	⨁◯◯◯ Very low^c^,^g	-	The mean communication - functional communication at ≥3 months was 83	MD 6.81 higher (1.4 higher to 12.22 higher)	MID = 4.0 (0.5 x median baseline SD)
Communication related quality of life (Assessment of Living with Aphasia, 0-4, higher values are better, final value) at <3 months	21 (1 RCT) follow-up: 6 weeks	⨁◯◯◯ Very low^c^,^f	-	The mean communication related quality of life at <3 months was 2.48	MD 0.35 higher (0.23 lower to 0.93 higher)	MID = 0.32 (0.5 x median baseline SD)
Communication related quality of life (Stroke aphasia quality of life-39 generic, 1-5, higher values are better, final value) at ≥3 months	34 (1 RCT) follow-up: 6 months	⨁⨁◯◯ Low^c^,^h	-	The mean communication related quality of life at ≥3 months was 3.35	MD 0.38 higher (0.08 lower to 0.84 higher)	MID = 0.30 (0.5 x median baseline SD)
Psychological distress - depression (Visual analog mood scales revised version, 0-100, lower values are better, final value) at <3 months	21 (1 RCT) follow-up: 6 weeks	⨁◯◯◯ Very low^c^,^f	-	The mean psychological distress - depression at <3 months was 55.7	MD 0.3 higher (13.72 lower to 14.32 higher)	MID = 6.4 (0.5 x median baseline SD)
Discontinuation at <3 months	41 (2 RCTs) follow-up: mean 7 weeks	⨁◯◯◯ Very low^e^,ⁱ	RD 0.00 (−0.13 to 0.13)	0 per 1,000	0 fewer per 1,000 (130 fewer to 130 more)^j	Sample size used to determine precision: 75-150 = serious imprecision, <75 = very serious imprecision.
Discontinuation at ≥3 months	108 (2 RCTs) follow-up: mean 5 months	⨁◯◯◯ Very low^c^,^k^,^l	RR 3.20 (0.52 to 19.62)	18 per 1,000	40 more per 1,000 (9 fewer to 339 more)	MID (precision) = RR 0.80 – 1.25.

a: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in measurement of the outcome)

b: Downgraded by 1 or 2 increments because heterogeneity, unexplained by subgroup analysis

c: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

d: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions and bias in measurement of the outcome)

e: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias due to deviations from the intended interventions)

f: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias in measurement of the outcome)

g: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process)

h: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to bias arising from the randomisation process)

i: Downgraded by 1 to 2 increments for imprecision due to zero events and small sample size

j: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

k: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviations from the intended interventions and bias in measurement of the outcome)

l: Downgraded for heterogeneity due to conflicting number of events in different studies (zero events in one or more studies)

Table 7Clinical evidence summary: computer-based tools for speech and language therapy compared to placebo

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with placebo	Risk difference with Computer-based tools for speech and language therapy	Comments
Communication - overall language ability (Western Aphasia Battery AQ, 0-100, higher values are better, change score) at <3 months	32 (1 RCT) follow-up: 6 weeks	⨁⨁◯◯ Low^a	-	-	MD 0.99 higher (0.5 higher to 1.48 higher)	MID = 8.83 (0.5 x median baseline SD)
Communication - overall language ability (Western Aphasia Battery AQ, 0-100, higher values are better, change score) at ≥3 months	46 (2 RCTs) follow-up: mean 3 months	⨁◯◯◯ Very low^a^,^b	-	-	MD 1.87 higher (0.14 lower to 3.88 higher)	MID = 8.83 (0.5 x median baseline SD)
Communication - impairment specific measures (naming) (naming accuracy, unclear scale range, higher values are better, final value, crossover trial) at <3 months	100 (1 RCT) follow-up: 6 weeks	⨁⨁◯◯ Low^c^,^d	-	The mean communication - impairment specific measures (naming) at <3 months was 13.99	MD 1.8 higher (1.51 lower to 5.11 higher)	MID = 4.3 (0.5 x median baseline SD)
Discontinuation at <3 months	32 (1 RCT) follow-up: 6 weeks	⨁◯◯◯ Very low^d^,^e	Peto OR 6.05 (0.56 to 65.53)	0 per 1,000	160 more per 1,000 (30 fewer to 350 more)^g	MID (precision) = Peto OR 0.80 – 1.25.
Discontinuation at ≥3 months	32 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low^d^,^e	RR 2.05 (0.49 to 8.63)	154 per 1,000	162 more per 1,000 (78 fewer to 1,000 more)	MID (precision) = RR 0.80 – 1.25.

a: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviations from the intended interventions, bias due to missing outcome data and bias in measurement of the outcome)

b: Downgraded by 1 or 2 increments because heterogeneity, unexplained by subgroup analysis

c: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to bias arising from the randomisation process)

d: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

e: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias due to deviations from the intended interventions and bias due to missing outcome data)

f: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

Table 8Health economic evidence profile: Computer-based tools for speech and language therapy versus usual care

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Latimer 2021²¹

(CACTUS)

(UK)

Directly applicable

Potentially serious limitations^(a)

Probabilistic model based on within-RCT analysis³⁴
Cost-utility analysis (QALYs)
Population: Adults with aphasia (defined by a score of 5–43/48 on the Comprehensive Aphasia Test (CAT) Naming Objects test) who had had a stroke at least 4 months previously.
Comparators:
1)
Usual care alone (UC)
2)
Computerised word finding therapy plus usual care (CSLT) (mean time spent practicing: 28 hours)
3)
Attention control plus usual care (AC)

Time horizon: lifetime

2−1: £733^(b)

2−3: £695^(b)

3-1: £38^(b)

2−1: 0.0172 QALYs

2−3: 0.0173 QALYs

3−1: −0.0001 QALYs

CSLT versus UC: £42,686 per QALY gained (not cost-effective)

CSLT versus AC: £40,164 per QALY gained (not cost-effective)

AC versus UC: Dominated (AC had higher costs and lower QALYs)

Probability of cost effective (£20K/£30K threshold):

Usual care: 56%/45%,
CSLT: 22%/32%,
Attention control: 22%/22%.

ICERs for subgroups with moderate word finding difficulties were £13,673 per QALY gained for CSLT compared to AC plus usual care alone, which was the only cost-effective result found, and £21,262 per QALY gained for CSLT compared to usual care alone. Alternative costing assumptions (including the inclusion of volunteer costs) did not change conclusions on cost-effectiveness.

Latimer 2013²²

(Big CACTUS)

(UK)

Partially applicable^(c)

Potentially serious limitations^(d)

Probabilistic model based on within-RCT analysis³⁹
Cost-utility analysis (QALYs)
Population: Adults with a diagnosis of stroke and aphasia with word finding difficulties as one of the predominant features as assessed by the Comprehensive Aphasia Test (CAT) and the Object and Action Naming Battery.
Comparators:
○ 1)
Usual stimulation (normal language stimulation activities and support groups)
2)
Computerised word finding and reading therapy (home-based) plus usual stimulation (CSLT) (mean time practicing: 25 hours)
Time horizon: lifetime

£436.87^(e)

0.14 QALYs

£3,058

Results of the model were sensitive to the utility gain (for example: utility gain of ≤0.01 resulted in ICER of >£20,000) and relapse rate parameters (for example: relapse rate of >30% resulted in ICER of >£20,000 (from a base case relapse rate of 0.08%)).

ICER increased to £39,491 when 50% decrease to the base case utility gain (0.035 from 0.07) and increasing the relapse rate to 30% per month after month 5.

: Abbreviations: ICER= incremental cost-effectiveness ratio; HRQoL= health-related quality of life; QALY= quality-adjusted life years; RCT= randomised controlled trial; SLT = speech and language therapy.

(a): The lifetime model was based on an RCT with a short follow up (12 months) and focused on one piece of software which could affect the generalisability of the analysis. The health-related quality of life benefit associated with a good response to computerised therapy was small and uncertain, making it difficult to ascertain whether adding computerised therapy to usual care leads to a QALY gain compared to usual care alone. Accessible version of the EQ-5D-5L questionnaire is not yet validated, and although this allows utility (HRQoL) scores to be elicited directly from people with aphasia, whose language difficulties may make it difficult to complete standard EQ-5D-5L questionnaires. Only direct intervention costs were included as Big CACTUS did not collect data on wider resource use, due to the pilot study finding no important differences in indirect resource use associated with computerised therapy compared to usual care.

(b): 2017 UK pounds. Cost components incorporated: intervention costs only including hardware and software costs (computers, including StepByStep software licences, headphones, puzzle books); SLT training costs; SLT, SLTA and volunteer time costs and travel costs.

(c): 2010 Unit costs may not reflect current UK NHS context and year of resource use estimates not reported.

(d): The lifetime model was based on an RCT with a short follow up (8 months) and focused on one piece of software which could affect the generalisability of the analysis. Resource use was not estimated from a systematic review but from self-reported questionnaire. The utility of non-responders was assumed to be equal for the intervention group and control group, which overlooks the possibility that the utility for non-responders in the intervention group could be lower than the utility in the control group. The validity of the definition of a ‘good response’ is uncertain, as it was arbitrarily defined as those who demonstrated a word-finding improvement that was better than the average increase observed in the experimental group. Accessible version of the EQ-5D-5L questionnaire is not yet validated, although this allows utility (HRQoL) scores to be elicited directly from people with aphasia, whose language difficulties may make it difficult to complete standard EQ-5D-5L questionnaires. Finally, it should be noted that the sample size of the CACTUS trial was small (n=34) and aimed to assess the feasibility of a rigorous RCT of a self-managed computer therapy. Therefore, it cannot be expected to provide conclusive cost-effectiveness results.

(e): 2010 UK pounds. Cost components included: Intervention costs, including the cost of computers, Step-by-Step software, microphones, and the cost of SLT training and support, which including setting up and assisting patients with the computer program. Resource use included GP, nurse, and other health care professional visits and consultations, as well as hospital admissions, appointments, and prescribed medication.

Table 9Unit costs of health care professionals who may be involved in delivering interventions involving computer-based tools for speech and language therapy

Resource	Cost per working hour (hospital / community)^(a)	Source
Band 5 SLT	£40/£42	PSSRU 2021¹⁸
Band 6 SLT	£53/£56
Band 7 SLT	£64/£67
Rehabilitation assistant	£33/£32	PSSRU 2021¹⁸, estimated based on agenda for change band 3 salary^(b)

: Abbreviations: PSSRU= personal social services research unit; SLT= speech and language therapist.

(a): Note: Costs per working hour include salary, salary oncosts, overheads (management and other non-care staff costs including administration and estates staff), capital overheads and qualification costs.

(b): Band 3 not in PSSRU 2021 so salary was assumed to equal Band 3 Mean annual basic pay per FTE for administration and estates staff, NHS England (PSSRU2021 p.149).

Table 10Example costs of computer-based tools for the treatment of aphasia

Computer-based tool	Cost	Source
Claro Software^(a)	£59/£215	Single Units of ClaroRead SE/ClaroRead⁹
Web ORLA^(b)	£58	Shirley Ryan Ability Lab⁴¹
PowerAFA^(c)	£56/£116/£258	Base (one patient/5 computers)/ Professional (10 patients/ 8 computers)/Ultimate life-time licence (No limit to patients, up to 15 computers.⁴⁰
StepbyStep© software^(d)	£250/£550/£2200	Steps Consulting Ltd.⁴³ StepByStep aphasia therapy. Individual licence; clinician licence; clinician 5-licence

(a): Reported in Caute 2019⁶ $85 converted using PPP³⁵

(b): Reported in Cherney 2021⁸

(c): Reported in De Luca 2018¹¹

(d): Palmer 2020³⁸

Table 11Summary costs from Marshall 2020²⁶

	Total cost (£, 2017–18 prices)
	North	East	South	West	Mean
Total cost for training^(a)	£4,627	£1,738	£3,826	£3,465	£3,414
Total cost for project manager inputs to groups^(b)	£1,835	£858	£1,416	£1,027	£1,284
Total cost for coordinator inputs to groups^(c)	£2,610	£1,470	£1,829	£2,220	£2,032
Total cost for volunteer inputs to groups^(d)	£829	£1,034	£779	£1,018	£915
Total hardware costs^(e)	£1,245	£967	£697	£692	£901
Total software costs^(f)	£1,416	£1,416	£1,416	£1,416	£1,416
TOTAL COST FOR GROUP (inc. hardware)	£12,562	£7,483	£9,963	£9,838	£9,961
TOTAL COST FOR GROUP (exc. hardware)	£11,316	£6,516	£9,265	£9,146	£9,061
Average cost per participant (exc. hardware)	£2,263	£724	£1,324	£1,143	£1,364
Average cost per online attendance (exc. hardware)	£195	£68	£101	£91	£114

(a): Training consisted of two 4-hour sessions for coordinators and volunteers

(b): 2017/18 Hourly cost for an NHS community based SLT principal obtained from PSSRU 2018¹⁰

(c): £29.99 per working hour. Calculation assumes a co-ordinator salary of £27581 p.a., 30% salary on-costs at £8274 p.a. and 30% institutional overheads upon total salary at £10757. Working time assumed as 42 working weeks p.a./37 hours per week. Co-ordinator base salary obtained from figures used in research funding proposal.

(d): Hour of leisure time (£6.86); DoT document reports the perceived cost of non-working time for ‘other’ purpose to be £6.04 at 2010 prices. 2010 value uprated to 2017/18 prices using GDP inflator of 13.6%, obtained from PSSRU 2018¹⁰. Value of leisure time obtained from the Department for Transport (2014): Transport Analysis Guidance (TAG).¹²

(e): Laptop cost (£135): Purchase price assumed as £810 for a ‘gaming’ laptop (e.g., HP ProBook 450 2017). Per user cost assumed as 1/6 of full cost based on 6-month loan and 3-year life span. (Cost not annuitised). Headset £3.33: Purchase price assumed as £20. Per user cost assumed as 1/6 of full cost based. Ethernet cable (£1.33) Purchase price assumed as £8. Per user cost assumed as 1/6 of full cost based on 6-month loan and 3-year life span (Cost not annuitised); Dongle (£5).

(f): Software hosting (£38.25), Last bill paid by project = 435.60 Euros for one year. This is equivalent to £383 per year (or £31.92 per month) based on an average 2017/18 currency conversion rate of 0.8793.¹⁷ Assuming that a group runs for 6 months, and uses only 20% of the software’s capacity, the total cost per group = £38.

Table 19Studies excluded from the clinical review

Study	Code [Reason]
Agostini, M., Garzon, M., Benavides-Varela, S. et al. (2014) Telerehabilitation in poststroke anomia. BioMed Research International 2014 (no pagination) [PMC free article: PMC4009336] [PubMed: 24829914]	- Data not reported in an extractable format or a format that can be analysed Reported F and p values only with no values that can be used to calculate mean and SD values
Brady, Mc, Kelly, H, Godwin, J et al. (2016) Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews [PMC free article: PMC8078645] [PubMed: 27245310]	- Systematic review used as source of primary studies Cochrane review investigating speech and language therapy that is not just computer based. References checked.
Braley, M, De, Oliveira E, Munsell, M et al. (2020) A Phase II Randomized, Virtual, Clinical Trial of Speech Therapy App for Speech, Language, and Cognitive Intervention in Stroke. Archives of Physical Medicine and Rehabilitation 101(11): e62	- Conference abstract
Cacciante, L., Kiper, P., Garzon, M. et al. (2021) Telerehabilitation for people with aphasia: A systematic review and meta-analysis. Journal of Communication Disorders 92: 106111 [PubMed: 34052617]	- Systematic review used as source of primary studies
Chiaramonte, R.; Pavone, P.; Vecchio, M. (2020) Speech rehabilitation in dysarthria after stroke: a systematic review of the studies. European journal of physical & rehabilitation medicine. 56(5): 547–562 [PubMed: 32434313]	- Study does not contain an intervention relevant to this review protocol Included computer based and non-computer based speech and language therapy. References checked.
Chiaramonte, R. and Vecchio, M. (2021) Dysarthria and stroke. The effectiveness of speech rehabilitation. A systematic review and meta-analysis of the studies. European journal of physical & rehabilitation medicine. 57(1): 24–43 [PubMed: 32519528]	- Duplicate reference
Choe, Y. K., Azuma, T., Mathy, P. et al. (2007) The effect of home computer practice on naming in individuals with nonfluent aphasia and verbal apraxia. Journal of Medical Speech-Language Pathology 15(4): 407–421	- Non-randomised study that does not account for confounding factors
Crerar, M. A. and Ellis, A. (1995) Computer-based therapy for aphasia: towards second generation clinical tools. The treatment of aphasia: from theory to practice.: 222–250	- Study design not relevant to this review protocol
Cross, E. (2014) Cost effectiveness of Aphasia Computer Treatment versus Usual Stimulation or attention control long term post stroke: a randomised trial.	- Clinical trial registry data only
De Cock, E. (2019) Tablet-based aphasia therapy in the chronic phase.	- Clinical trial registry data only
Dial, H. R., Hinshelwood, H. A., Grasso, S. M. et al. (2019) Investigating the utility of teletherapy in individuals with primary progressive aphasia. Clinical Interventions In Aging 14: 453–471 [PMC free article: PMC6394239] [PubMed: 30880927]	- Population not relevant to this review protocol Primary progressive aphasia rather than stroke-induced aphasia
Fink, R. B., Brecher, A., Sobel, P. et al. (2005) Computer-assisted treatment of word retrieval deficits in aphasia. Aphasiology 19(10–11): 943–954	- Study design not relevant to this review protocol Case series
Fuentes, B., de la Fuente-Gomez, L., Sempere-Iborra, C. et al. (2022) DUbbing Language-therapy CINEma-based in Aphasia post-Stroke (DULCINEA): study protocol for a randomized crossover pilot trial. Trials [Electronic Resource] 23(1): 21 [PMC free article: PMC8734327] [PubMed: 34991688]	- Protocol only
Giachero, A., Calati, M., Pia, L. et al. (2020) Conversational Therapy through Semi-Immersive Virtual Reality Environments for Language Recovery and Psychological Well-Being in Post Stroke Aphasia. Behavioural Neurology 2020: 2846046 [PMC free article: PMC7428879] [PubMed: 32831969]	- Data not reported in an extractable format or a format that can be analysed No values provided that could be used consistently to calculate standard deviations for all groups
Goodenough-Trepagnier, C. (1990) Early intervention with globally aphasic stroke patients using a computerized visual communication technique. Journal of rehabilitation research and development 28(1): 369–370	- Conference abstract
Guo, Y. E., Togher, L., Power, E. et al. (2017) Assessment of Aphasia Across the International Classification of Functioning, Disability and Health Using an iPad-Based Application. Telemedicine Journal & E-Health 23(4): 313–326 [PubMed: 27802112]	- Study does not contain an intervention relevant to this review protocol Computer based program to assess aphasia rather than conduct rehabilitation therapy
Harrison, M. (2019) Evaluating the intervention fidelity of self-managed computer therapy for aphasia post-stroke. Evaluating the intervention fidelity of self-managed computer therapy for aphasia post-stroke	- Thesis only Discusses a trial that has been included in the review (Big CACTUS trial)
Harvey, S.; Baird, A.; Meltzer, J. A. (2015) Evaluation of TeleRehab effectiveness for post-stroke communication disorders. International journal of stroke 10(suppl4): 83	- Conference abstract
Huang, L., Chen, S. K., Xu, S. et al. (2021) Augmentative and alternative communication intervention for in-patient individuals with post-stroke aphasia: study protocol of a parallel-group, pragmatic randomized controlled trial. Trials [Electronic Resource] 22(1): 837 [PMC free article: PMC8611624] [PubMed: 34819130]	- Study does not contain an intervention relevant to this review protocol Not computer based speech and language therapy
Kim, E. S., Laird, L., Wilson, C. et al. (2021) Implementation and Effects of an Information Technology-Based Intervention to Support Speech and Language Therapy Among Stroke Patients With Aphasia: Protocol for a Virtual Randomized Controlled Trial. JMIR Research Protocols 10(7): e30621 [PMC free article: PMC8285741] [PubMed: 34255727]	- Protocol only
Laganaro, M.; Di Pietro, M.; Schnider, A. (2006) Computerised treatment of anomia in acute aphasia: treatment intensity and training size. Neuropsychological rehabilitation 16(6): 630–640 [PubMed: 17127569]	- Population not relevant to this review protocol 3 out of 8 participants had a traumatic brain injury instead of a stroke
Lee, J., Fowler, R., Rodney, D. et al. (2010) IMITATE: An intensive computer-based treatment for aphasia based on action observation and imitation. Aphasiology 24(4): 449–465 [PMC free article: PMC2882655] [PubMed: 20543997]	- Protocol only
Lee, Jaime B. and Cherney, Leora R. (2016) Computer-Based Treatments for Aphasia: Advancing Clinical Practice and Research. Perspectives of the ASHA Special Interest Groups 1(2): 5–17	- Systematic review used as source of primary studies Included single arm trials
Palmer, R.; Enderby, P.; Paterson, G. (2013) Using computers to enable self-management of aphasia therapy exercises for word finding: the patient and carer perspective. International Journal of Language & Communication Disorders 48(5): 508–21 [PubMed: 24033650]	- Study design not relevant to this review protocol Qualitative study
Penaloza, C., Scimeca, M., Gaona, A. et al. (2021) Telerehabilitation for Word Retrieval Deficits in Bilinguals With Aphasia: Effectiveness and Reliability as Compared to In-person Language Therapy. Frontiers in Neurology 12 (no pagination) [PMC free article: PMC8172788] [PubMed: 34093382]	- Comparator in study does not match that specified in this review protocol The study is a retrospective analysis of a trial randomised to whether someone receives therapy in their language of choice or not.
Repetto, C., Paolillo, M. P., Tuena, C. et al. (2021) Innovative technology-based interventions in aphasia rehabilitation: a systematic review. Aphasiology 35(12): 1623–1646	- Systematic review used as source of primary studies Includes studies with no control group
Stachowiak, F. J. (1994) Computers in aphasia rehabilitation. Brain injury and neuropsychological rehabilitation.: 133–160	- Data not reported in an extractable format or a format that can be analysed Does not report data that could be used to calculate standard deviations
Stark, B. C. and Warburton, E. A. (2018) Improved language in chronic aphasia after self-delivered iPad speech therapy. Neuropsychological rehabilitation 28(5): 818–831 [PubMed: 26926872]	- Crossover trial that does not report outcomes for each phase
Stark, B. C. and Warburton, E. A. (2015) “CATCH study” - computerised aphasia therapy in chronic aphasia: using self-administered iPad-delivered speech therapy to explore language improvements in post-stroke chronic expressive aphasia. Cerebrovascular diseases (Basel, Switzerland) 39(suppl2): 119	- Conference abstract
Thunstedt, D. C., Young, P., Kupper, C. et al. (2020) Follow-up in aphasia caused by acute stroke in a prospective, randomized, clinical, and experimental controlled noninvasive study with an ipad-based app Neolexon: Study protocol of the lexi study. Frontiers in Neurology 11 (no pagination) [PMC free article: PMC7212356] [PubMed: 32425873]	- Duplicate reference
Thunstedt, D. C., Young, P., Kupper, C. et al. (2020) Follow-Up in Aphasia Caused by Acute Stroke in a Prospective, Randomized, Clinical, and Experimental Controlled Noninvasive Study With an iPad-Based App (Neolexon R): Study Protocol of the Lexi Study. Frontiers in neurology [electronic resource]. 11: 294 [PMC free article: PMC7212356] [PubMed: 32425873]	- Protocol only
Uslu, A. S., Gerber, S. M., Schmidt, N. et al. (2020) Investigating a new tablet-based telerehabilitation app in patients with aphasia: a randomised, controlled, evaluator-blinded, multicentre trial protocol. BMJ Open 10(11): e037702 [PMC free article: PMC7661375] [PubMed: 33177134]	- Protocol only
West, C, Hesketh, A, Vail, A et al. (2005) Interventions for apraxia of speech following stroke. Cochrane Database of Systematic Reviews [PMC free article: PMC8769681] [PubMed: 16235357]	- Systematic review used as source of primary studies Cochrane review. Only includes people with aphasia of speech. Included no studies.
Woodhead, Z. V. J., Kerry, S. J., Aguilar, O. M. et al. (2018) Randomized trial of iReadMore word reading training and brain stimulation in central alexia. Brain 141(7): 2127–2141 [PMC free article: PMC6118228] [PubMed: 29912350]	- Comparator in study does not match that specified in this review protocol Compares people receiving transcranial direct current stimulation to people who received sham therapy (while both groups also received the iReadMore app)

Evidence reviews for computer-based tools for speech and language therapy

1. Computer-based tools for speech and language therapy

1.1. Review question

1.1.1. Introduction

1.1.2. Summary of the protocol

1.1.3. Methods and process

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Population factors

Types of computer-based tools

Intensity of therapy

Inconsistency

1.1.4.2. Excluded studies

1.1.5. Summary of studies included in the effectiveness evidence

1.1.5.1. Summary matrix

1.1.6. Summary of the effectiveness evidence

1.1.7. Economic evidence

1.1.7.1. Included studies

1.1.7.2. Excluded studies

1.1.8. Summary of included economic evidence

1.1.9. Economic model

1.1.10. Unit costs

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

1.1.12.2. The quality of the evidence

1.1.12.2.1. Computer-based tools compared to speech and language therapy without computer-based tools

1.1.12.2.2. Computer-based tools compared to social support/stimulation

1.1.12.2.3. Computer-based tools compared to no treatment

1.1.12.2.4. Computer-based tools compared to placebo

1.1.12.3. Benefits and harms

1.1.12.3.1. Key uncertainties

1.1.12.3.2. Computer-based tools compared to speech and language therapy without computer-based tools, social support/stimulation, no treatment and placebo

1.1.12.4. Cost effectiveness and resource use

1.1.12.5. Other factors the committee took into account

1.1.13. Recommendations supported by this evidence review

1.1.14. References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

Appendix C. Effectiveness evidence study selection

Appendix D. Effectiveness evidence

Appendix E. Forest plots

Appendix F. GRADE tables

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Appendix I. Health economic model

Appendix J. Excluded studies

Clinical studies

Health Economic studies

Appendix K. Research recommendations – full details

Table 1PICO characteristics of review question

Table 2Summary of studies included in the evidence review

Table 3Summary matrix of computer-based tools for speech and language therapy compared to each comparison groups

Table 4Clinical evidence summary: computer-based tools for speech and language therapy compared to speech and language therapy without computer-based tools (usual care)

Table 5Clinical evidence summary: computer-based tools for speech and language therapy compared to social support/stimulation

Table 6Clinical evidence summary: computer-based tools for speech and language therapy compared to no treatment

Table 7Clinical evidence summary: computer-based tools for speech and language therapy compared to placebo

Table 8Health economic evidence profile: Computer-based tools for speech and language therapy versus usual care

Table 9Unit costs of health care professionals who may be involved in delivering interventions involving computer-based tools for speech and language therapy

Table 10Example costs of computer-based tools for the treatment of aphasia

Table 11Summary costs from Marshall 202026

Table 19Studies excluded from the clinical review

Table 11Summary costs from Marshall 2020²⁶