Mapping the contribution of Allied Health Professions to the wider public health workforce: a rapid review of evidence-based interventions.

Objectives: The objective was to identify a selection of the best examples of the public health contributions by Allied Health Professionals (AHPs) in order to encourage a wider awareness and participation from that workforce to public health practice. Study design: A mapping exercise was used to identify evidence-based interventions that could lead to health improvements across a population. Methods: A rapid review was undertaken to identify evidence, followed by a survey of Allied Health Profession (AHP) practitioners and an expert panel consensus method to select the examples of AHP public health interventions. Results: Nine evidence-based interventions are identified and selected as examples of current AHP good practice. These examples represent a contribution to public health and include screening interventions, secondary prevention and risk management. Conclusions: This study contributes to a strategy for AHPs in public health by appraising the effectiveness and impact of some exemplar AHP practices that contribute to health improvement. There is a need for AHPs to measure the impact of their interventions and to demonstrate evidence of outcomes at population level.

The effect of estradiol, progesterone, and melatonin on estrous cycling and ovarian aromatase expression in intact female mice.

OBJECTIVE: Melatonin and progesterone levels decline during the perimenopause. Both hormones inhibit estrogen action and endometrial cancer, but little is known about how they act in combination. Therefore, the interplay of progesterone (P4) and melatonin was investigated in intact female mice. STUDY DESIGN: Three P4 doses, low (25mg), mid (50mg), and high (100mg), combined with 0.5mg 17ß-estradiol (E), were administered in the diet (per 1800kcal) for 30 days. Hormone therapy (HT) with the low P4 dose (estradiol/low progesterone replacement therapy (EPLRT)) was used to create an excess estrogen environment to mimic perimenopause. Half the mice were treated with melatonin (M) 15mg/L in the drinking water at night. RESULTS: The unbalanced EPLRT treatment increased estrogen-regulated responses. Specifically, mice treated with EPLRT had significantly higher levels of ovarian aromatase mRNA versus control, which was prevented in the presence of higher doses of P4 and/or the addition of melatonin. The number of days in estrus also increased in EPLRT-treated versus control mice with no change in the length or number of complete estrous cycles. Melatonin, combined with all doses of P4, increased the number of days spent in estrus, but not the length or number of estrous cycles compared to melatonin alone; however, two-way ANOVA revealed a significant interaction between melatonin and P4 dose for days in estrus and for number of cycles. Although none of the E2 and P4 combinations significantly affected uterine weight compared to control, melatonin addition to the low or mid P4 HT resulted in slightly higher uterine weights compared to melatonin-treated mice. Melatonin significantly increased uterine estrogen receptor alpha (ERα) and progesterone receptor A levels compared to control animals. HT, added in combination with melatonin, reduced ERα levels back to control levels, but PR levels remained elevated albeit intermediary to those achieved with melatonin alone. CONCLUSION: The findings that melatonin supplementation inhibits ovarian aromatase expression and increases uterine receptors in mice given an HT that mimics perimenopause may have important clinical applications for the improvement of menopause-related conditions, like menorrhagia, associated with high levels of E2 and low levels of P4.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. A randomised controlled trial.

OBJECTIVES: To test the hypotheses that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR) and that HBR is less costly. DESIGN: Two-arm randomised controlled trial. SETTING: Four trusts in England providing both HBR and DHR. PARTICIPANTS: Clinical staff reviewed consecutive referrals to identify subjects who were potentially suitable for randomisation according to the defined inclusion criteria. INTERVENTIONS: Patients were randomised to receive either HBR or DHR. MAIN OUTCOME MEASURES: The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) scale. Secondary outcome measures included the EuroQol 5 dimensions (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Therapy Outcome Measures (TOMs), hospital admissions and the General Health Questionnaire (GHQ-30) for carers. RESULTS: Overall, 89 subjects were randomised and 42 received rehabilitation in each arm of the trial. At the primary end point of 6 months there were 32 and 33 patients in the HBR and DHR arms respectively. Estimated mean scores on the NEADL scale at 6 months, after adjustment for baseline, were not significantly in favour of either HBR or DHR [DHR 30.78 (SD 15.01), HBR 32.11 (SD 16.89), p = 0.37; mean difference -2.139 (95% CI -6.870 to 2.592)]. Analysis of the non-inferiority of HBR over DHR using a 'non-inferiority' limit (10%) applied to the confidence interval estimates for the different outcome measures at 6 months' follow-up demonstrated non-inferiority for the NEADL scale, EQ-5D and HADS anxiety scale and some advantage for HBR on the HADS depression scale, of borderline statistical significance. Similar results were seen at 3 and 12 months' follow-up, with a statistically significant difference in the mean EQ-5D(index) score in favour of DHR at 3 months (p = 0.047). At the end of rehabilitation, a greater proportion of the DHR group showed a positive direction of change from their initial assessment with respect to therapist-rated clinical outcomes; however, a lower proportion of HBR patients showed a negative direction of change and, overall, median scores on the TOMs scales did not differ between the two groups. Fewer patients in the HBR group were admitted to hospital on any occasion over the 12-month observation period [18 (43%) versus 22 (52%)]; however, this difference was not statistically significant. The psychological well-being of patients' carers, measured at 3, 6 and 12 months, was unaffected by whether rehabilitation took place at day hospital or at home. As the primary outcome measure and EQ-5D(index) scores at 6 months showed no significant differences between the two arms of the trial, a cost-minimisation analysis was undertaken. Neither the public costs nor the total costs at the 6-month follow-up point (an average of 213 days' total follow-up) or the 12-month follow-up point (an average of 395 days' total follow-up) were significantly different between the groups. CONCLUSIONS: Compared with DHR, providing rehabilitation in patients' own homes confers no particular disadvantage for patients and carers. The cost of providing HBR does not appear to be significantly different from that of providing DHR. Rehabilitation providers and purchasers need to consider the place of care in the light of local needs, to provide the benefits of both kinds of services. Caution is required when interpreting the results of the RCT because a large proportion of potentially eligible subjects were not recruited to the trial, the required sample size was not achieved and there was a relatively large loss to follow-up. TRIAL REGISTRATION: Current Controlled Trials ISRCTN71801032.

Knock-down of RGS4 and beta tubulin in CHO cells expressing the human MT1 melatonin receptor prevents melatonin-induced receptor desensitization.

Previously, it has been shown that chronic melatonin exposure in MT1-CHO cells results in receptor desensitization while at the same time producing drastic morphological changes. The addition of a depolymerizing agent during the melatonin pretreatment period prevents MT1 receptor desensitization and the changes in cellular morphology. The lack of morphological change in the presence of a depolymerizing agent is easily explained by the inability of the microtubules to polymerize, however, the prevention of receptor desensitization is a little more complex and may involve G-protein activation. The goal of this study was to determine whether melatonin-induced MT1 receptor desensitization is regulated by proteins known to regulate G-protein activation states, beta-tubulin and RGS4,using anti sense knockdown approaches. The expression of RGS4 mRNA in CHO cells was confirmed using RT PCR and successful knockdown of each was confirmed by western blot analysis or quantitative PCR. Pretreatment of MT1-CHO cells, transfected with the nonsense probes and exposed to melatonin, resulted in a desensitization of the receptor, an increase in forskolin-induced cAMP accumulation, an increase in 2-[125I]-iodomelatonin binding and no change in the affinity of melatonin for the MT1 receptor. However, knockdown of either beta-tubulin or RGS4 in MT1-CHO cells followed by pretreatment with melatonin attenuated the desensitization of melatonin receptors, decreased total 2-[125I]-iodomelatonin binding, and did not affect neither the forskolin response nor the affinity of melatonin for the MT1 receptor. Perhaps RGS4 and beta-tubulin modulate Galpha-GDP and Galpha-GTP states thus modulating MT1 melatonin receptor function.

A 12-month follow-up of preschool children investigating the natural history of speech and language delay.

AIM: The aim of this paper is to examine the natural history of early speech and language delay in preschool children over a 12-month period. METHODS: The study reports data on 69 children under the age of 3.5 years who were referred for speech and language therapy because of early speech and language delay. The children were monitored over a 12-month period but received no direct intervention during that time. Assessment of their comprehension, expressive language and their phonology took place at baseline and again at 6 and 12 months after baseline. RESULTS: The results show a general picture of improvement, although there was considerable individual variation. By the end of the 12 months, two-thirds of the children were still eligible on the study intake criteria. Therapist's rating of a child's functional communication at the outset was a significant predictor of the child's outcome at the end of the 12-month period. DISCUSSION: The paper discusses the appropriateness of a 'monitoring' approach to the management of early language delay and highlights the need to consider the social issues and views of parents as well as the severity of a child's difficulties.

Pharmacological treatment for aphasia following stroke.

BACKGROUND: Aphasia describes language impairment associated with a brain lesion. OBJECTIVES: The objective of this review was to assess the effects of drugs on language abilities when given to people with aphasia following stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Register (last searched: May 2001), and reference lists of relevant articles to December 1998. We also contacted academic institutions and other researchers to identify further published and unpublished trials. MEDLINE was searched from 1966-1998, and CINAHL from 1982-1998. We searched the International Journal of Disorders of Communication by hand (known by other names in the past), from 1969 to 1998. SELECTION CRITERIA: Randomised controlled trials comparing: ~bullet~Any drug given to improve language, versus no treatment, or versus placebo ~bullet~Any drug given to improve language versus speech and language therapy ~bullet~One drug given to improve language versus another drug given with the same aim DATA COLLECTION AND ANALYSIS: The principal reviewer collected the data, and assessed the quality of the trials with independent data checking and methodological advice. If we could not perform a statistical combination of different studies, we sought missing data. Failing that we provided a description. We sought missing data from authors, or where appropriate, a drug company. MAIN RESULTS: We considered fifty two studies in detail, from which we identified ten trials suitable for the review. In most cases the methodological quality was unassessable, and only one trial reported sufficient detail for us to complete a description and analysis. This study did lose a large number of patients during its course. Drugs used in the trials identified were piracetam, bifemalane, piribedil, bromocriptine, idebenone, and Dextran 40. We found weak evidence that patients were more likely to have improved on any language measure at the end of the trial if they had received treatment with piracetam (odds ratio 0.46, 95% confidence interval 0.3 to 0.7). The evidence is considered weak because of the large numbers of drop outs from the trials identified, who were lost to follow up. Patients who were treated with piracetam were no more likely (considering statistical significance) than those who took a placebo to experience unwanted effects, including death (odds ratio 1.29, 95% confidence interval for difference 0.9 to 1.7). However, the differences in death rates between the two groups, even though not not statistically significant, do give rise to some concerns that there may be an increased risk of death from taking piracetam. We could not determine if drug treatment is more effective than speech and language therapy. We could not determine whether one drug is more effective than another. REVIEWER'S CONCLUSIONS: The main conclusion of this review is that drug treatment with piracetam may be effective in the treatment of aphasia after stroke. Further research is needed to explore the effects of drugs for aphasia, in particular piracetam. If a trial is done, this must be large enough to have adequate statistical power. The safety of the drug should be of primary interest. Researchers should examine the long term effects of this treatment, and whether it is more effective than speech and language therapy.

Down-regulation of mt1 melatonin receptors in rat ovary following estrogen exposure.

In this study, we have demonstrated that 2-[125I]-iodomelatonin binds specifically to rat ovarian granulosa cell (GC) membranes with high affinity (KD=83 pM; Bmax=3.28 fmol/mg protein). Using immunoblot analysis and an anti-mt1 melatonin receptor antibody, we have also detected mt1 melatonin receptors in rat ovary. Because melatonin has been reported to alter the steroidogenic responses of ovarian tissues to gonadotropins, a physiological role for intra-ovarian melatonin may exist. Thus, in order to investigate a possible intra-ovarian role for melatonin, we have used both an in vivo and in vitro model of follicular development. Treatment of immature (day 21) female rats with estradiol (E; 0.2 mg/d x 3 d; subcutaneous) was used to induce follicular growth. Membranes from both untreated (U) and E-treated animals' ovaries contained high-affinity 2-[125I]-iodomelatonin (I-MEL) binding sites (Kd=83 and 23 pM, respectively). Estradiol treatment in vivo caused a significant decrease (P<0.05) in binding of 2-[125I]-iodomelatonin to ovarian membranes with untreated animals' ovaries having a Bmax=3.28 fmol/mg protein vs. estradiol-treated animals' ovaries having a Bmax=0.92 fmol/mg protein. In addition, following Estradiol treatment, mt1 melatonin receptors in rat ovary were down-regulated (approximately 95%) using immunoblot analysis. Granulosa cells isolated from E-treated rats were further matured in vitro with testosterone (T) and the pituitary gonadotropin follicle-stimulating hormone (FSH). Granulosa cells were cultured with either T (10 ng/ml) or FSH (5.71 ng ovine FSH-20/ml) alone, or both FSH and T for 48 h. There was no statistically significant specific binding of 2-[125I]-iodomelatonin to GC membranes cultured with T or FSH alone. However, following a 48-h exposure to FSH and T in vitro specific 2-[125I]-iodomelatonin binding occurred with total 2-[125I]-iodomelatonin binding =3.15 [corrected] fmol/mg protein. Therefore, the existence of hormonally-regulated expression of high-affinity melatonin binding sites suggests that melatonin may have an important intra-ovarian physiological role.

Benchmarking can facilitate the sharing of information on outcomes of care.

Recent restructuring in the national health service (NHS) aimed to effect cultural and organisation changes that would ensure fair and equal access for service users to effective and efficient services. Clinical governance has been introduced as a means of delivering quality improvement. One element of this is the use of benchmarking to assess current process and outcome and to use comparative information to inform about current and best practice. The use of the Therapy Outcome Measure (TOM) (Enderby and John 1997) was investigated as an indicator to benchmark the outcomes of treatment for different client-groups and compare patterns of outcomes from different speech and language therapy (SLT) services. The study recruited eight SLT trust sites and ran for eighteen months. The TOM data was analysed to note similarities and differences in cases entering treatment, in the direction of change resulting from treatment, and on completing treatment. Variation was found on these points between cases with different disorders and across the trusts. TOM data could be used to provide a benchmark for a disorder against which services could make comparisons. However, for benchmarking to succeed there is a need for support and commitment from every level of an organisation.

Informing educational change to improve clinical competence.

The factors that have influenced the current approaches to speech and language therapy education in Great Britain are discussed. A project is presented which will provide data on how educational approaches can more clearly reflect professional practice.

Day in, day out: the everyday therapy of community clinics.

This paper describes the timing and nature of therapy provided within a recent randomised controlled trial (RCT) of preschool speech and language therapy services. There is literature that describes and evaluates speech and language therapy but there is little indication of how this is translated into everyday practice. The study collected data from 21 speech and language therapists (SLTs) in 16 community clinics. The areas targeted, goals, approaches used, the frequency and timing of contact for the 68 children who received treatment were documented. The data show that several aspects of therapy were frequently targeted simultaneously, that approaches were combined and that the frequency of therapy did not vary with severity. The discussion will consider the gap between published programmes and everyday practice and the implications for effectiveness.

Who's afraid of the randomised controlled trial? Parents' views of an SLT research study.

Evidence-based health care is now a reality within the national health service (NHS) and the randomised controlled trial (RCT) is the linchpin of this movement. In modern health care, there has also been a shift towards understanding client perspectives. With regard to clients' participation in research, much consideration has been given to ethical issues and barriers to participation. However, less attention has been paid to the participants' views of clinical trials and understanding how they construe the research. This paper reports a study of the attitudes of parents whose children took part in an RCT. Data were collected from the parents of 20 children, using qualitative in-depth interviews. Parents talked about the meaning of their participation, their motivation for taking part and their understanding of the nature of the trial. The implications of the findings for future research will be considered.

N1E-115 mouse neuroblastoma cells express MT1 melatonin receptors and produce neurites in response to melatonin.

Melatonin, a pineal hormone that induces sleep, has become a popular over-the-counter drug. The cellular effects of melatonin, however, are only beginning to be studied. We have recently shown that stimulation of the MT1 melatonin receptor induces rapid and dramatic cytoskeletal rearrangements in transformed non-neuronal cells (Witt-Enderby et al., Cell. Motil. Cytoskel. 46 (2000) 28). These cytoskeletal changes result in the formation of structures that closely resemble neurites. In this work, we show that the N1E-115 mouse neuroblastoma cell line rapidly responds to melatonin stimulation and forms neurites within 24 h. We also demonstrate that these cells readily bind 2-[125I]iodomelatonin at levels consistent with what is noted for native tissues (B(max)=3.43+/-1.56 fmol/mg protein; K(d)=240 pM). Western analysis shows that these cells possess and express melatonin receptors of the MT1 subtype. Treatment with pertussis toxin eliminates neurite formation whereas treatment with the MT2 subtype-specific activator, BMNEP, does not induce neurite formation. We have previously shown that increases in MEK 1/2 and ERK 1/2 phosphorylation are correlated with the shape changes in transformed CHO cells. Western analysis of the MEK/ERK signaling pathway in N1E-115 cells shows that this pathway is most likely maximally and constitutively stimulated. This may account for the spontaneous production of neurites noted for this cell line after long culture periods. The results of this work show that melatonin receptor stimulation in a neuronal cell type results in the formation of neurites and that the receptors responsible for melatonin-induced neurite formation in N1E-115 cells are most likely of the MT1 subtype.

Demographic and epidemiological analysis of patients referred to speech and language therapy at eleven centres 1987-95.

This retrospective study analyses data collected on an information system developed specifically for the use of speech and language therapists and the management of their services. The age, gender, medical diagnoses, and speech and language therapy diagnoses associated with the referral of > 73,000 clients to 11 speech and language therapy providers between 1987 and 1995 are reviewed. In 1987, 34.8% of the patients referred to speech and language therapy did not have a formal medical diagnosis and this was commonly associated with children with speech and language delay or disorders. However, by 1995, the group not having a formal medical diagnosis had fallen to 17.2% of referrals. Whereas in 1987, 22.7% of the referrals with a medical diagnosis to speech and language therapy were associated with stroke, this has increased in 1995 to 32.0%. Dysphagia represented 0.94% of the referrals in 1987 but 20.6% of referrals in 1995. The gender balance of referrals has remained remarkably constant over the period of study: 60% of referrals were male and 40% female. Whilst nearly half of all referrals were aged under 5 years, the proportion of all referrals represented by this age group has fallen slightly over these years. This has been matched by an increase in the proportion of the caseload aged over 70.

Developing a scale to measure parental attitudes towards preschool speech and language therapy services.

In the past decade, there has been growing recognition of the need to involve clients in decisions about the healthcare they receive and in the evaluation of services offered. In health services research, survey and scaling methods have become important tools for research into 'consumer views' and the perspectives of people receiving healthcare. In spite of the increase in recent years in the participation of parents in their children's Speech and Language Therapy (SLT), there has been little attempt to investigate parents' perceptions and opinions of the services they receive. Moreover, there has been no previous attempt to derive a scale to measure these attitudes. The paper reports a study that explored the attitudes to therapy of 81 parents whose preschool children were receiving SLT intervention. Factor analysis of 12 items on a questionnaire revealed three issues salient in parental attitudes to therapy: practical help, emotional support and the perceived effectiveness of the service. The validity of these factors was supported by other findings from the questionnaire. The properties of the resulting scales are discussed and the ways in which they might be further refined and developed for use in SLT are suggested.

Community rehabilitation in the United Kingdom.

OBJECTIVE: To investigate the extent and nature of community rehabilitation services within the United Kingdom. DESIGN: A postal survey starting with the Community Rehabilitation Network and extending to any other teams identified or making contact. SETTING: The National Health Service within the UK. SUBJECTS: Any team who identified themselves as a community rehabilitation service that worked 'primarily with adults with physical disability' within the UK. INTERVENTION: A questionnaire was sent to each team identified with follow-up telephone contact to clarify answers and/or to encourage replies. RESULTS: One hundred and fifty-two organizations were sent questionnaires and 145 replied, but 47 were excluded for various reasons leaving 98 valid replies. Four types of team were identified: community rehabilitation teams, young disabled community teams, community teams for older adults, and specific client group teams. There were huge variations in management arrangements, team composition, goals of the services and likely lifespan of the service. CONCLUSIONS: Community rehabilitation in the UK is currently characterized by small, often short-term teams with poor identity and the term has no clear or consistent meaning.

Randomised controlled trial of community based speech and language therapy in preschool children.

OBJECTIVE: To compare routine speech and language therapy in preschool children with delayed speech and language against 12 months of "watchful waiting." DESIGN: Pragmatic randomised controlled trial. SETTING: 16 community clinics in Bristol. PARTICIPANTS: 159 preschool children with appreciable speech or language difficulties who fulfilled criteria for admission to speech and language therapy. MAIN OUTCOME MEASURES: Four quantitative measures of speech and language, assessed at 6 and 12 months; a binary variable indicating improvement, by 12 months, on the trial entry criterion. RESULTS: Improvement in auditory comprehension was significant in favour of therapy (adjusted difference in means 4.1, 95% confidence interval 0.5 to 7.6; P=0.025). No significant differences were observed for expressive language (1.4, -2.1 to 4.8; P=0.44); phonology error rate (-4.4, -12.0 to 3.3; P=0.26); language development (0.1, -0.4 to 0.6; P=0.73); or improvement on entry criterion (odds ratio 1.3, 0.67 to 2.4; P=0.46). At the end of the trial, 70% of all children still had substantial speech and language deficits. CONCLUSIONS: This study provides little evidence for the effectiveness of speech and language therapy compared with watchful waiting over 12 months. Providers of speech and language therapy should reconsider the appropriateness, timing, nature, and intensity of such therapy in preschool children. Continued research into more specific provision to subgroups of children is also needed to identify better treatment methods. The lack of resolution of difficulties for most of the children suggests that further research is needed to identify effective ways of helping this population of children.

Reliability of speech and language therapists using therapy outcome measures.

The Therapy Outcome Measure (TOM) aims to provide Speech and Language Therapists (SLT) with a practical tool to measure outcomes of care by providing a quick and simple measure which can be used over time with patients and clients in a routine clinical setting. The TOM allows therapists to reflect their clinical judgement on the dimensions of impairment, disability/activity, handicap/participation and well-being on an 11-point ordinal scale. The purpose of this paper is to examine the reliability and the influences on reliability of SLT using this measure. Three studies are presented and give information on 73 SLT using the measure with different client groups. Study one assesses the degree of reliability of six SLT using the TOM following training and practice. Reliability was studied on three occasions and the results demonstrate the influence of training and practice. Study two included 56 SLT to examine reliability over a broader range of client groups and to investigate the effect of the SLT specializing on rating patients from within or -out that specialism. Eleven therapists were included in the study, which examined the influence of a specific training approach. The participating SLT achieved a substantial-moderate level of reliability; this was established in all domains. The degree of reliability achieved on the TOM was affected by some, but not extensive, training and experience.

Melatonin induction of filamentous structures in non-neuronal cells that is dependent on expression of the human mt1 melatonin receptor.

Melatonin has gained recent popularity as a treatment for insomnia and other sleep disorders; however, its cellular effects are unknown. We report the effects of melatonin on the cellular morphology of Chinese hamster ovary (CHO) cells transformed to express the human melatonin receptors, mt1 and MT2. Our results show that melatonin exerts a strong influence on cellular shape and cytoskeletal organization in a receptor-dependent and possibly subtype-selective manner. The cell shape change that we see after a 5-h treatment of these non-neuronal cells with a pharmacological concentration of melatonin consists of the formation of long filamentous outgrowths that are reminiscent of the neurite processes produced by differentiating nerve cells. This morphological change occurs exclusively in cells expressing the mt1 receptor. We find that the microtubule and microfilament organization within these outgrowths is similar to that of neurites. Microtubules are required for the shape change to occur as Colcemid added in combination with melatonin completely blocks outgrowth formation. We demonstrate that the number of cells showing the altered cell shape is dependent on melatonin concentration, constant exposure to melatonin and that outgrowth frequencies increase when protein kinase A (PKA) is inhibited. Concomitant melatonin-dependent increases in MEK 1/2 and ERK 1/2 phosphorylation are noted in mt1-CHO cells only. The production of filamentous outgrowths is dependent on the translation of new protein but not the transcription of new mRNA. Outgrowth number is not controlled by centrosomes but is instead controlled by the polymerization state of the actin cytoskeleton. The results of this work show that the organization of the cytoskeleton is affected by processes specifically mediated or regulated by the mt1 receptor and may represent a novel alternative mechanism for the stimulation of process formation.

Speech and language therapy for aphasia following stroke.

BACKGROUND: Aphasia describes language impairment associated with a brain lesion. OBJECTIVES: The objective of this review was to assess the effects of formal speech and language therapy and non-professional types of support from untrained providers for people with aphasia after stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched: March 1999), and reference lists of relevant articles to December 1998. We also contacted academic institutions and other researchers to identify further published and unpublished trials. We searched The International Journal of Disorders of Communication by hand (known by other names in the past), from 1969 to 1998. Date of most recent searches: January 1999. SELECTION CRITERIA: Randomised controlled trials comparing: 1. Any type of formal speech and language therapy in any setting administered by trained speech and language therapists versus no treatment. 2. Any type of formal speech and language therapy in any setting administered by trained speech and language therapists versus any type of informal support for aphasia, given by speech and language therapists or volunteers, whether these were trained or untrained. 3. One type of speech and language therapy versus another type. Outcome measures included measures of any type of communication, other measures of functioning, numbers of drop-outs, and other non-clinical outcomes. DATA COLLECTION AND ANALYSIS: The principal reviewer collected the data, and assessed the quality of the trials with independent data checking and methodological advice. If we could not perform a statistical combination of different studies, we sought missing data. Failing that we provided a description. MAIN RESULTS: We considered sixty studies in detail, from which we identified twelve trials suitable for the review. Most of these trials were relatively old with poor or unassessable methodological quality. None of the trials was detailed enough for us to complete description and analysis. We could not determine whether formal speech and language therapy is more effective than informal support. REVIEWER'S CONCLUSIONS: The main conclusion of this review is that speech and language therapy treatment for people with aphasia after a stroke has not been shown either to be clearly effective or clearly ineffective within a RCT. Decisions about the management of patients must therefore be based on other forms of evidence. Further research is required to find out if effectiveness of speech and language therapy for aphasic patients is effective. If researchers choose to do a trial, this must be large enough to have adequate statistical power, and be clearly reported.

An analysis of referrals to speech and language therapy in 11 centres, 1987-95.

This retrospective study analyses data collected on an information system developed specifically for the use of speech and language therapists in the management of their services. Eleven healthcare providers have used the system since 1985. This paper reflects data on 73,000 clients referred to these speech and language therapy services between 1987 and 1995. The annual referral rate to these 11 trusts in 1987 was 4129, rising to 11,944 in 1995. The percentage referrals per head of population per year varies between 0.32 and 0.58% of the population. Of referrals to speech and language therapy, 96% comes from 24 different sources, including self referrals and referrals from other agencies, such as education. The top five referrers in 1987 were health visitors, educational service, general medicine/geriatrics, general practitioners (GPs), and other speech and language therapists. In 1995 ear, nose and throat (ENT) services replaced speech and language therapists in the top five referrers.