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Clarification of conclusions from the ACT NoW trial

Nature Reviews Neurology volume 9, page 118 (2013)Cite this article

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An article by Alex Leff and David Howard in the November issue of Nature Reviews Neurology (Stroke: Has speech and language therapy been shown not to work? Nat. Rev. Neurol. 8, 600–601)1 discusses our recent article published in The BMJ.2 We are saddened that Howard, a member of the ACT NoW Trial Steering Committee, is critical of the trial and welcome the opportunity to respond. We have some concern that therapists unfamiliar with the original publications2,3,4 or with randomized trial methodology may be misled by the debate. Leff and Howard focus on secondary questions and do not acknowledge that the first imperative for an evidence base is to establish whether an intervention is effective.

Leff and Howard raise three concerns. First, they query the control over constituents of both interventions. Speech and language therapy (SLT) is, as they acknowledge, a complex intervention that varies according to an individual's needs. In the ACT NoW trial, therapists agreed upon a range of SLT activities and tailored their intervention within that range to the perceived needs of each patient. A trial of a 'one-size-fits-all' therapy would have attracted justifiable criticism. For the control group, 'visitors' were trained and monitored to ensure that they did not deliver anything considered as therapy; they certainly did not provide conversation therapy—a promising technique that merits further clinical research.

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References

  1. Leff, A. P. & Howard, D. Has speech and language therapy been shown not to work? Nat. Rev. Neurol. 8, 600–601 (2012).

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  2. Bowen, A. et al. Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial. BMJ 345, e4407 (2012).

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  3. Bowen, A. et al. Clinical effectiveness, cost effectiveness and service users' perceptions of early, well-resourced communication therapy following a stroke, a randomised controlled trial (The ACT NoW Study). Health Technol. Assess. 16, 1–160 (2012).

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  4. Young, A. et al. Trial participants' experiences of early, enhanced speech and language therapy after stroke compared with employed visitor support: a qualitative study nested within a RCT. Clin. Rehabil. http://dx.doi.org/10.1177/0269215512450042.

  5. Brady, M. C., Kelly, H., Godwin, J. & Enderby, P. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews Issue 5. Art. No.: CD000425. http://dx.doi.org/10.1002/14651858.CD000425.pub3.

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Acknowledgements

ACT NoW was commissioned and funded by the UK's NIHR Health Technology Assessment Programme (ref. 02/1104) and published in full in Health Technology Assessment. Excess treatment costs were covered by the Department of Health and the Stroke Association. The views and opinions expressed in this paper do not necessarily reflect those of the NIHR, NHS, UK Department of Health or the Stroke Association.

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Authors and Affiliations

  1. The University of Manchester MAHSC, Stroke and Vascular Research Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK

    Audrey Bowen &  Pippa Tyrrell

  2.  Centre for Biostatistics, R&D Support Unit, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK

    Andy Vail

  3.  Ellen Wilkinson Building, University of Manchester MAHSC, Oxford Road, Manchester, M13 9PL, UK

    Anne Hesketh, Emma Patchick & Mo Wilkinson

  4.  Jean MacFarlane Building, University of Manchester MAHSC, Oxford Road, Manchester, M13 9PL, UK

    Alys Young & Linda Davies

  5.  Zochonis Building, University of Manchester MAHSC, Oxford Road, Manchester, M13 9PL, UK

    Matthew A. Lambon Ralph

  6.  Health Systems Research, School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9UT, UK

    Andrew F. Long

  7.  Speakeasy, c/o 2 Purbeck Drive, Bolton, BL6 4JF, UK

    Gill Pearl

  8.  Stroke Practice Research Unit, University of Central Lancashire, Preston, PR1 2HE, UK

    Caroline Watkins

  9.  Academic Section of Geriatric Medicine, Level 3, Centre Block, Royal Infirmary, Glasgow, G4 OSF, UK

    Peter Langhorne

Authors
  1. Audrey Bowen
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  2. Anne Hesketh
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  3. Emma Patchick
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  7. Andrew F. Long
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  12. Pippa Tyrrell
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  13. Peter Langhorne
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Correspondence to Audrey Bowen.

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The authors declare no competing financial interests.

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Bowen, A., Hesketh, A., Patchick, E. et al. Clarification of conclusions from the ACT NoW trial. Nat Rev Neurol 9, 118 (2013). https://doi.org/10.1038/nrneurol.2012.211-c1

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