Cochrane Database of Systematic Reviews

Interventions for apraxia of speech following stroke (Review)

West C, Hesketh A, Vail A, Bowen A

West C, Hesketh A, Vail A, Bowen A.

Interventions for apraxia of speech following stroke.
Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004298.
DOI: 10.1002/14651858.CD004298.pub2.

www.cochranelibrary.com

Interventions for apraxia of speech following stroke (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Interventions for apraxia of speech following stroke (Review) i

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Interventions for apraxia of speech following stroke

Carolyn West1 , Anne Hesketh2 , Andy Vail3 , Audrey Bowen2

1 Rehabilitation
Services, Hope Hospital, Manchester, UK. 2 HCD, School of Psychological Sciences, Ellen Wilkinson Building, Uni-
versity of Manchester, Manchester, UK. 3 Health Methodology Research Group, University of Manchester, Salford, UK

Contact address: Carolyn West, Rehabilitation Services, Hope Hospital, Stott Lane, Salford, Manchester, M6 8HD, UK.
[email protected].

Editorial group: Cochrane Stroke Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 7 December 2004.

Citation: West C, Hesketh A, Vail A, Bowen A. Interventions for apraxia of speech following stroke. Cochrane Database of Systematic
Reviews 2005, Issue 4. Art. No.: CD004298. DOI: 10.1002/14651858.CD004298.pub2.

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

Apraxia of speech is a communication disorder that can affect stroke patients. Several different intervention strategies are undertaken
by speech and language therapists working with this patient group.

Objectives

To assess whether therapeutic interventions improve functional speech in stroke patients with apraxia of speech and which individual
therapeutic interventions are effective.

Search methods

We searched the Cochrane Stroke Group Trials Register (searched May 2004). In addition, we searched the following databases: the
Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003); MEDLINE (1966 to April 2004); EMBASE
(1980 to April 2004); CINAHL (1982 to April 2004); PsycINFO (1974 to April 2004); the National Research Register (searched
April 2004); and Current Controlled Trials Register (searched May 2004). We reviewed reference lists of relevant articles and contacted
authors and researchers in an effort to identify published and unpublished trials.

Selection criteria

We sought to include randomised controlled trials of non-drug interventions for adults with apraxia of speech following a stroke where
the primary outcome was functional speech at six months follow up.

Data collection and analysis

One author searched the titles, abstracts and keywords. Two authors examined the abstracts that might meet the inclusion criteria. Four
authors were available to assess trial quality and to extract data from eligible studies.

Main results

No trials were identified.

Interventions for apraxia of speech following stroke (Review) 1
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors’ conclusions

There is no evidence from randomised trials to support or refute the effectiveness of therapeutic interventions for apraxia of speech.
There is a need for high quality randomised trials to be undertaken in this area.

PLAIN LANGUAGE SUMMARY

Interventions for apraxia of speech following stroke

No evidence was found for the treatment of apraxia of speech, a communication disorder that can affect stroke patients. Patients with
apraxia of speech know what they want to say, but are unable to carry out the speech movements due to their inability to programme
the required sequence. For example, a patient may be able to say goodbye when leaving someone (automatic), but not when asked to
say goodbye out of context (volitional). Several types of treatment interventions have been identified; however, we were unable to find
any clinical trials of these.

BACKGROUND define and assess AOS in order to plan rehabilitation interventions.

Traditionally, AOS has been thought of as a disorder of motor pro-
The World Health Organization has defined stroke as ’a syndrome
gramming, ’an articulatory disorder resulting from impairment,
of rapidly developing clinical signs of focal (or global) disturbance
due to brain damage, of the capacity to program the positioning
of cerebral function, with symptoms lasting 24 hours or longer or
of speech musculature for the volitional production of phonemes
leading to death, with no apparent cause other than vascular in
and the sequencing of muscle movements for the production of
origin’ (WHO 1978). Stroke is the biggest cause of severe disabil-
words’ (Darley 1975). However, there has been heated debate over
ity in England and Wales (Wolfe 1996) with 100,000 first strokes
the last 30 years about its true nature (Code 1998; Miller 2000)
occurring each year (Blais 1994). Stroke can affect people’s physi-
and currently there is no universally agreed definition of AOS.
cal, sensory and cognitive abilities (Wade 1985).
Definitions of AOS have been evolving within different theoretical
Apraxia is the broad label used to refer to the underlying neu- frameworks: behavioural, cognitive and neuro-anatomical (Croot
ropsychological deficits that can affect stroke (and other neurolog- 2002), acoustic and phonetic-perceptual (Ballard 2000). Despite
ical) patients in their performance of skilled voluntary movements the high level of theoretical interest it is unclear to what extent
of various parts of the body, for example, limb apraxia and oral each framework is useful in differential diagnosis with other com-
apraxia (Lezak 1995). Apraxia can affect the performance of every- munication impairments such as aphasia and dysarthria.
day activities such as self-care (washing or cooking) and commu-
nicating with others (using the telephone or writing) in the home
A further challenge to research in this area is that AOS is of-
or broader community settings such as leisure and employment.
ten accompanied by other linguistic (aphasia) and motor exe-
A commonly-used definition of the apraxias is ’disorders of the
cution (dysarthria) disorders. Interested readers are referred to
execution of learned movement which cannot be accounted for by
the Cochrane systematic reviews of aphasia (Greener 2003) and
either weakness, incoordination, or sensory loss, or by incompre-
dysarthria (Sellars 2003). AOS is believed to commonly co-oc-
hension of or inattention to command’ (Geschwind 1975). Oral
cur with aphasia, which may also result in sound errors in speech
apraxia is defined as the ’inability to efficiently and immediately
(phonemic paraphasias), but many studies fail to describe the way
produce oral movements on verbal command and/or imitation
in which aphasia and AOS coexist. The Apraxia Battery for Adults
with preserved ability to produce similar actions semi-automati-
(ABA) (Dabul 2000) has been used in some studies in diagnos-
cally’ (Roy 1985). These oral movements, such as blowing a kiss,
ing AOS (O’Connell 1985; Rogers 1999; Towne 1988; Waters
may be unrelated to speech.
1992). However, the ABA does not discriminate between aphasic
Apraxia of speech (AOS) is a communication disorder usually (phonological) impairments and AOS, and its standardisation is
treated by speech and language therapists. In AOS speech sounds limited. Moreover, few published tests for dysarthria and apha-
are made in an erratic way in the absence of muscle weakness. sia are specific about differential diagnosis of these disorders from
There is considerable controversy in the literature about how to AOS.
Interventions for apraxia of speech following stroke (Review) 2
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Although there is so much theoretical debate and no commonly lips together and then blowing to prepare for the production of p
agreed definition it has recently been demonstrated that speech and and b sounds;
language therapists working in clinical practice can make highly
reliable diagnostic and severity decisions about AOS (Mumby • phonetic placement: targets the segmental level of
2005). Inter-rater and intra-rater reliability were both high even production, the focus being the position of the articulator.
though therapists in this study only viewed a brief video clip and Clinicians use models, drawing, verbal descriptions and physical
did not have access to any assessment results. We would argue manipulation to demonstrate how a speech sound is produced;
that this is support for the belief that therapists in clinical practice • key word: the patient is enabled to consistently produce a
recognise the difficulties experienced by people with AOS. There core vocabulary and when successful the core vocabulary is
are core symptoms that consistently form part of the diagnostic expanded by using similar words;
description. These have been reviewed (Code 1998; Ballard 2000;
McNeil 2000) and include: • phonetic placements or minimal pairs or both: speech
stimuli are established that vary minimally relative to features
• effortful ’groping’ for articulatory postures and therefore such as manner, place and voicing;
difficulty forming the correct orofacial position to produce the
• voluntary control of involuntary utterances (VCIU): the
correct sound;
patient learns to control when they verbalise their utterances
• more consonant than vowel errors occur as the consonant (repeated sounds) using a visual-verbal model;
part of the word is more difficult to produce;
• multiple input phoneme therapy (MIPT): patients control
• inconsistent or variable errors occur therefore each attempt when the utterances are produced using an auditory-verbal
at the word could produce a different result; approach;
• production of words or speech sounds or both that • prosodic therapy: therapists work on the rate, stress and
approximate the target word and therefore the word may sound intonation of a word or utterance.
similar to the target but not the same;
• difficulty producing adjacent consonants, for example Unfortunately there is no current expert opinion to support ther-
inserting additional vowel sounds; and apy for AOS. Although they cover speech disorders and mention
• awareness of errors. articulatory dyspraxia , neither the Royal College of Physicians of
London’s Clinical Guidelines (IWP 2004) nor the Scottish Clini-
People with AOS tend to know what they want to say, but appear cal Guidelines (SIGN 2002) make specific recommendations for
unable to carry out the speech motor action. As in other apraxias therapy for AOS.
there appears to be a disparity between automatic and volitional There are no good epidemiological data on the prevalence of
behaviour. For example, a patient may be able to say goodbye when apraxia of speech, no doubt due to the challenges described above.
leaving the company of someone (automatic), but not when asked However, it has been described as ’not infrequent’ (Varley 2001)
to say goodbye out of context (volitional).They are unable easily and, despite the lack of good data, AOS is a communication dis-
to position their articulators (the points in the vocal tract involved order treated by speech and language therapists in clinical prac-
in producing sounds). Instead articulatory ’groping’ occurs, often tice. The evidence suggests that it occurs following a lesion of the
with perseveration (repeated production of the same sound) and language-dominant hemisphere (McNeil 2000). In this review we
the correct word may not be produced. shall confine the discussion of apraxia to that affecting speech.
Several types of treatment interventions for apraxia of speech have Oral apraxia will be included only if it is concurrent with apraxia
been listed (Square-Storer 1989). Therapy in severe cases may start of speech.
by focusing on non-speech movements (oral apraxia) before focus-
ing on speech sounds (apraxia of speech). Treatment techniques
include: OBJECTIVES
• prompts for restructuring oral muscular phonetic targets To assess whether therapeutic interventions improve functional
(PROMPT): the therapist places their fingers on the face and speech in stroke patients with apraxia of speech and which indi-
neck to give feedback about the articulatory position required for vidual therapeutic interventions are effective.
specific speech sounds;
• phonetic derivation: shaping of sounds based on their non-
speech postures or action plans or both, for example putting the METHODS

Interventions for apraxia of speech following stroke (Review) 3

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Criteria for considering studies for this review (5) The quality of speech at the scheduled end of the intervention.
(6) Non-verbal communication.
(7) Mood.
Types of studies (8) Quality of life measures.
(9) Adverse events.
We planned to include randomised controlled trials of interven-
(10) Effects on family and carer, for example stress, illness, and
tions for stroke patients with apraxia of speech with or without
carer’s mood.
oral apraxia. We aimed to exclude second and subsequent phases
(11) Carer and family perceptions of outcome.
of cross-over trials from analysis, as the design would not be ap-
(12) Financial costs, for example cost effectiveness and cost benefit.
propriate in this context.

Types of participants Search methods for identification of studies

The review was confined to adults with apraxia of speech identi- See: ’Specialized register’ section in Cochrane Stroke Group
fied by the original authors following a stroke. Adults with oral We searched the Cochrane Stroke Group Trials Register which
apraxia or other speech difficulties, for example aphasia, were in- was last searched by the Review Group Co-ordinator on 11 May
cluded only if they also had apraxia of speech. Trials that included 2004. We also searched the following databases: the Cochrane
participants whose deficits were the result of head trauma, brain Central Register of Controlled Trials (The Cochrane Library Issue
tumour or other brain damage were excluded unless a subgroup 4, 2003); MEDLINE (1966 to April 2004); EMBASE (1980 to
of stroke patients were identified for whom there were separate April 2004); CINAHL (1982 to April 2004); PsycINFO (1974 to
results, or more than 75% of patients in the sample were stroke April 2004); the National Research Register (searched April 2004);
patients. and Current Controlled Trials Register (http://www.controlled-
trials.com/) (searched May 2004) (Appendix 1).
We had planned to handsearch a number of relevant journals.
Types of interventions
However, after checking the Master List of journals that is searched
Trials were included if a comparison were made between an ac- by The Cochrane Collaboration (http://www.cochrane.us/mas-
tive treatment group that received one of the various apraxia of terlist.asp), we found that the selected journals had already been
speech interventions versus a control group that received either an handsearched. The resulting trials would, therefore, be found from
alternative apraxia of speech intervention, placebo or none. Possi- our search of the Cochrane Central Register of Controlled Trials
ble treatment interventions included: PROMPT, phonetic deriva- and we did not wish to duplicate effort.
tion, phonetic placement, key word, minimal pairs, VCIU, MIPT We searched the reference lists of all relevant references.
and prosodic therapy. Trials including a combination of drug and We attempted to find both published and unpublished work by:
therapy were excluded. • contacting authors of published apraxia of speech articles to
ask if they were aware of any relevant studies; and
• writing to key international publications read by those
Types of outcome measures
treating and researching apraxia of speech (Aphasiology, Royal
The primary outcome was functional speech at the latest follow College of Speech and Language Therapists Bulletin, The
up within six months after therapy. We planned to use recognised Psychologist, Clinical Rehabilitation).
measures, for example The Communicative Effectiveness Index
CETI (Lomas 1989).
Secondary outcomes were as follows.
Data collection and analysis
(1) Functional speech at the scheduled end of intervention. Recog-
nised measures, for example the Communicative Effectiveness In-
dex (CETI) (Lomas 1989), were used.
(2) The amount of connected speech at the scheduled end of the Selection of trials
intervention; for example, on picture description, ’Cookie Theft’ The agreed protocol was that:
(Goodglass 1983). In the absence of this, single-word level was • one author would search the titles, abstracts and keywords
used; for example, the Boston Naming Test (Kaplan 1983). and discard papers that obviously did not meet the inclusion
(3) The amount of connected speech at six months after therapy. criteria;
(4) Quality of speech at six months after therapy was measured • two authors would screen any abstracts that might meet the
using intelligibility tests, for example the Assessment of Intelligi- inclusion criteria;
bility of Dysarthric Speech (Yorkston 1981). In the absence of this, • all authors would read the remaining studies and form a
measures of accuracy were used (per cent of consonants correct). consensus on the final inclusion.

Interventions for apraxia of speech following stroke (Review) 4

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Quality assessment outcomes that were treated as continuous. It was envisaged that
All four authors would assess the methodological quality of any the death rates between the two groups would be low and similar
included studies for the following aspects: because studies would only have included patients who were well
• concealment of allocation (whether adequate, inadequate, enough to undergo rehabilitation for AOS. Any imbalance in death
or unclear); rates between the groups would be discussed, including descriptive
• type of design (e.g. parallel, crossover, factorial); consideration of whether analyses of raw data from individual trials
• blinding to allocation (of therapist, patient and outcome could alter conclusions.
assessor); Where possible, results for continuous outcomes were to be com-
• definition of terms, (e.g. of ’stroke’, ’apraxia’, outcome, and bined using weighted mean difference by a fixed-effect model.
intervention); However, it was anticipated that studies would use different scales
• intention-to-treat analysis (whether undertaken, possible to measure the same underlying constructs. If this were the case,
from report, impossible or unclear); the standardised mean difference would be used. Results for bi-
• completeness of follow up (proportion of randomised nary outcomes were to be combined using the Peto-modified odds
patients in analysis). ratio, and translated to risk differences across the observed range
of control group rates for reporting purposes. We planned to note
and discuss statistical heterogeneity.
Data extraction We aimed to carry out sensitivity analyses on the primary outcome.
These would include use of a random-effects analysis, omission
In addition to outcome data, we planned that all authors would
of studies that did not describe an adequate method of allocation
document the following:
concealment, and imputing values for missing data if appropriate.
(1) settings (e.g. hospital, community, nursing home);
(2) type of intervention;
(3) length of rehabilitation;
(4) profession(s) involved;
(5) co-interventions implemented; RESULTS
(6) length of disease (acute or chronic);
(7) level of severity;
(8) presence of other symptoms that might affect the level of dis-
Description of studies
ability (for example dysarthria);
(9) tools the authors used to identify apraxia of speech; The literature search identified around 1000 titles. There was con-
(10) the percentage of participants with oral apraxia were recorded siderable duplication as many were found in each of the databases.
if available. Most were not relevant to interventions for AOS. If the title clearly
We planned to request from the corresponding author any infor- identified a study that was not relevant to AOS it was discarded
mation that was unclear or missing from the reports. at that point. Abstracts of the remaining articles were screened
for inclusion or exclusion; however, no article met the inclusion
criteria. Therefore, there were no full articles on which we could
Data analysis conduct quality assessment, data extraction or data analysis. We
Our agreed protocol was that our primary analysis would pool did not identify any non-English language titles but would seek
all therapeutic studies of active intervention versus control or no translation of any that result from updated searches.
treatment to address our first objective. To address our second
objective, we planned to analyse subgroups of studies categorised
according to therapeutic approach, as outlined under ’Types of Risk of bias in included studies
interventions’. This would include a comparison of each approach
versus control or no treatment, as well as direct comparisons of No studies were found.
different approaches.
Speech production scales (accuracy and intelligibility) and other
ordinal scales were to be treated as continuous outcomes unless Effects of interventions
and until accepted meta-analytic techniques for ordinal outcome
No studies were available for analysis.
data became available. If two measures of the same construct were
presented we would favour the more widely-recognised measure. If
changes from baseline were recorded we planned to use these data.
Means and standard deviations were to be abstracted, calculated or
requested. For practical reasons, deaths were to be excluded from DISCUSSION

Interventions for apraxia of speech following stroke (Review) 5

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Apraxia of speech occurs following stroke and other neurological proaches most commonly used for AOS. However, there is con-
conditions. Speech and language therapists use many differing siderable resistance within speech and language therapy to the use
treatment techniques in clinical practice (Square-Storer 1989) yet of randomised trials (Pring 2004). Whilst there are certain clinical
there are no recommendations for therapy in either of two recent questions about AOS that cannot be answered by a randomised
Clinical Guidelines (IWP 2004; SIGN 2002). Despite conducting trial there are others that can, including questions of clinical and
a comprehensive literature search that resulted in thousands of cost effectiveness.
’hits’, there is currently no evidence from randomised trials to
support or refute the therapeutic approach or management for
AOS after stroke. We feel that our broad search strategy would
AUTHORS’ CONCLUSIONS
have identified any eligible studies that existed and that this is not
a false negative finding. Instead, it is likely that the controversy
Implications for practice
surrounding the definition, and even the existence, of AOS may
have prevented people from attempting trials. Rehabilitation approaches to apraxia of speech following stroke
have yet to be supported or refuted by randomised trials. Inter-
Despite the lack of randomised trials, there is a large body of liter-
ested parties could source general guidance on current practice for
ature on the theoretical basis of AOS, much of it hypothesising on
communication disorders after stroke from the National Clinical
its relationship with aphasia. Whilst apraxia itself is a recognised
Guidelines for Stroke (IWP 2004), the Royal College of Speech
disabling condition (affecting skilled voluntary movements such
and Language Therapists (RCSLT 2004), and expert opinion.
as dressing and manual manipulation of everyday household ob-
jects) the possibility that apraxia might affect speech production is
Implications for research
more controversial. This is likely to be complicated by the co-oc-
currence of AOS and aphasia, as therapists and researchers express Apraxia of speech is a condition with a range of manifestations
concerns that it is not possible to differentially diagnose AOS. We and severity, and research continues to address theoretical ques-
recently conducted a study that found high levels of agreement tions about its nature and underlying impairment (Ballard 2000;
(both intra-rater and inter-rater reliability) between four speech Varley 2001; Ziegler 2003). Different severities may require dif-
and language therapists who independently diagnosed the pres- ferent types (rather than simply different intensities or ’dosage’) of
ence or absence of AOS in a sample of 42 stroke patients with intervention, depending on the functional outcome targeted (for
communication problems (Mumby 2005). Therapists were not example, more intelligible speech overall, intelligible production of
provided with any specific definition of AOS but were asked to use a core vocabulary, non-speech communication alternatives). This
their clinical judgement when viewing video tapes of structured review supports the need for randomised trials that compare po-
communication situations. Kappa values were high and this find- tentially appropriate interventions for carefully selected groups of
ing showed that despite the controversy in the literature, thera- people with apraxia after stroke. As effectiveness has not yet been
pists can make reliable differential diagnoses of AOS using clinical demonstrated for any of the individual therapy approaches, an at-
judgement. tention control comparator should be included. Trials should be
sufficiently large to identify clinically-relevant effects in functional
We do wish to acknowledge that there may be evidence from ran- communication. The therapeutic strategies, the pattern or severity
domised trials in other non-progressive clinical populations, such of apraxia and the various stages post stroke need to be clearly de-
as those with traumatic brain injury. Our review was restricted to fined. Trials should follow the Medical Research Council’s guide-
stroke but we now feel that future revisions should be expanded lines for evaluating complex interventions, which include pre-clin-
to include non-progressive neurological conditions. There is also ical work or theoretical work and modelling (MRC 2000). Key
a possible indirect source of randomised trial evidence on AOS; stakeholders should be included in planning future randomised
that it may be implicitly included within trials of other commu- trials, including service users and service providers.
nication difficulties, for example aphasia, and to a lesser extent
dysarthria. In clinical practice it is likely that therapists treat AOS Funding bodies and researchers should consider that it may be
as part of the overall communication intervention and not in iso- more cost effective to conduct a trial of AOS for non-progressive
lation. However, this review did not find that any of the aphasia or conditions rather than restricting it to stroke alone. This would
dysarthria trials were eligible for inclusion and so it is unsafe to ex- also increase the likelihood of recruiting the large numbers likely to
trapolate from them to AOS. Furthermore, both aphasia (Greener be needed for an adequately-powered trial. However, it would first
1999) and dysarthria (Sellars 2003) have been thoroughly system- be necessary to extend the current review to include the evidence
atically reviewed and both concluded there were no trials of suffi- from trials of other non-progressive conditions, such as traumatic
cient quality to guide practice. brain injury and encephalitis.

To ensure that best practice is implemented, good quality ran- Another possibility for funders to consider is to include AOS
domised trials need to be funded to evaluate the treatment ap- within a trial of intervention for other communication disorders,

Interventions for apraxia of speech following stroke (Review) 6

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
for example aphasia. The rationale for doing this is that it prob- they begin. Cochrane publications can be a powerful way of gen-
ably reflects what happens in clinical practice. However, it would erating interest from funding bodies, as the aphasia and dysarthria
require careful assessment for eligibility, development of an AOS reviews clearly demonstrate.
intervention procedure, and planned subgroup analyses so that
the evidence for AOS could be extracted from the overall evidence
collected. The UK’s Department of Health has recently funded a
major study that includes a randomised trial of speech and lan-
ACKNOWLEDGEMENTS
guage therapy intervention for aphasia and dysarthria after stroke
(ACT NoW Study). Unfortunately, the commissioning brief ex- We are grateful to the former North West Region NHS Executive
cluded AOS and other common communication problems such for funding Carolyn West’s postgraduate training fellowship for
as the acquired dyslexias and was restricted to the areas that had al- this review. Kath Mumby, a specialist speech and language ther-
ready been systematically reviewed. This last point highlights our apist with an interest in AOS, kindly helped us to formulate the
belief that systematic reviews should be conducted where there is definitions and describe the controversies within the profession
a clinical need even if the authors are not aware of any trials before concerning the nature of AOS (Mumby 2005).

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Darley FL, Aronson AE, Brown JR. Motor Speech Disorders. Nadeau E, Gonzalez Rothi LJ, Crosson B editor(s). Aphasia
Philadelphia: WB Saunders, 1975. and language: theory to practice. New York: The Guilford
Press, 2000:221–66.
Geschwind 1975
Geschwind N. The apraxias: neural mechanisms of Miller 2000
disorders of learned movements. American Scientist 1975; Miller N. Changing ideas in apraxia of speech.
63:188–95. In: Papathanasiou I editor(s). Acquired neurogenic
Goodglass 1983 communication disorders: A clinical perspective. London:
Goodglass H, Kaplan E. The assessment of aphasia and related Whurr, 2000:173–202.
disorders. Philadelphia: Lea & Febiger, 1983. MRC 2000
Greener 1999 Medical Research Council. A framework for development
Greener J, Enderby P, Whurr R. Speech and language and evaluation of RCTs for complex interventions to improve
therapy for aphasia following stroke (Cochrane review). health. London: Medical Research Council, 2000.
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Mumby 2005 Square-Storer 1989
Mumby K, Bowen A, Hesketh A. Reliably diagnosing AOS Square-Storer P. In: Square-Storer P editor(s). Acquired
(apraxia of speech) following stroke. Clinical Rehabilitation apraxia of speech in aphasic adults. Hove, London: LEA,
(in press). 1989.
O’Connell 1985 Towne 1988
O’Connell PF, Barber KL, O’Connell EJ. Phonological and Towne R, Crary M. Verbal reaction-time patterns in aphasic
syntactic effects in silent reading in aphasics with apraxia of adults - consideration for apraxia of speech. Brain and
speech. Folia Phoniatrica 1985;37(5-6):265–70. Language 1988;35(1):138–53.
Pring 2004 Varley 2001
Pring, T. Ask a silly question: a decade of troublesome Varley R, Whiteside S. Understanding the nature of apraxia
trials. International Journal of Language and Communication of speech: theory, analysis, and treatment. Aphasiology
Disorders 2004;39(3):285–302. 2001;15:39–49.
RCSLT 2004 Wade 1985
Royal College of Speech and Language Therapists. Royal Wade D, Skilbeck C, David R, Langton-Hewer R. Stroke:
College of Speech and Language Therapists Clinical Guidelines A critical approach to diagnosis, treatment and management.
(e-book). Oxford: Speechmark, 2004. London: Chapman and Hall, 1985.
Rogers 1999 Waters 1992
Rogers M, Redmond J. Parameters of semantic and Waters GS, Rochon E, Caplan D. The role of high-level
phonologic activation in speakers with aphasia with and speech planning in rehearsal - evidence from patients with
without apraxia of speech. Aphasiology 1999;13(9-11): apraxia of speech. Journal of Memory and Language 1992;31
871–86. (1):54–73.
Roy 1985 WHO 1978
Roy EA, Square PA. Common considerations in the study World Health Organization. Offset series No 43,
of limb, oral, and verbal apraxia. In: Roy EA editor(s). Cerebrovascular disease: a clinical and research classification.
Neuropsychological studies of apraxia and related disorders. Geneva: World Health Organization, 1978.
Amsterdam: North Holland, 1985:111–62.
Wolfe 1996
Sellars 2003
Wolfe C, Rudd A, Beech R. Stroke services and research. An
Sellars C, Hughes T, Langhorne P. Speech and language
overview with recommendations for future research. London:
therapy for dysarthria due to non-progressive brain damage
Stroke Association, 1996.
(Cochrane Review). Cochrane Database of Systematic Reviews
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14651858.CD002088] Yorkston K, Beukelman D. Assessment of the intelligibility of
dysarthric speech. Portland, OR: CC Publications, 1981.
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of patients with stroke: rehabilitation, prevention, and Ziegler W. Speech motor control is task-specific. Evidence
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Physicians, 2002. ∗
Indicates the major publication for the study

Interventions for apraxia of speech following stroke (Review) 8

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
This review has no analyses.

APPENDICES

Appendix 1. EMBASE search strategy

The search strategy for EMBASE is given below and this was modified for the other databases.
1. exp cerebrovascular disease/
2. (stroke$ or poststroke$ or cva$).tw.
3. (cerebrovascular$ or cerebral vascular).tw.
4. (cerebral or cerebellar or brainstem or vertebrobasilar).tw.
5. (infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$).tw.
6. 4 and 5
7. (cerebral or intracerebral or intracranial or parenchymal).tw.
8. (brain or intraventricular or brainstem or cerebellar).tw.
9. (infratentorial or supratentorial or subarachnoid).tw.
10. 7 or 8 or 9
11. (haemorrhage or hemorrhage or haematoma or hematoma).tw.
12. (bleeding or aneurysm).tw.
13. 11 or 12
14. 10 and 13
15. 1 or 2 or 3 or 6 or 14
16. Apraxia/ or dyspraxia/
17. psychomotor disorder/
18. motor performance/
19. psychomotor performance/ or task performance/
20. Cognitive Defect/
21. (aprax$ or dysprax$ or prax$ or practic).tw.
22. (psychomotor adj3 (disorder$ or performance or disturbance)).tw.
23. motor control/
24. Motor Dysfunction/
25. or/16-24
26. exp speech/
27. speech disorder/
28. speech rehabilitation/
29. speech therapy/
30. speech articulation/
31. speech perception/
32. speech analysis/
33. “speech and language”/
34. verbal communication/
35. verbalization/
36. communication disorder/
37. (speech or articulat$ or buccofacial or non-speech or oral or verbal or mouth).tw.
38. or/26-37
39. 25 and 38
40. speech apraxia/ or apraxia of speech/
Interventions for apraxia of speech following stroke (Review) 9
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
41. ((speech adj5 aprax$) or AOS).tw.
42. (phonetic disintegration or aphemia).tw.
43. ((motor or conduction) adj3 aphasia).tw.
44. or/40-43
45. 39 or 44
46. clinical trial/
47. multicenter study/
48. randomized controlled trial/
49. controlled study/
50. double blind procedure/
51. single blind procedure/
52. randomization/
53. placebo/
54. drug comparison/
55. clinical study/
56. (clin$ adj25 trial$).tw.
57. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).tw.
58. placebo$.tw.
59. random$.tw.
60. longitudinal study/
61. prospective study/
62. “evaluation and follow up”/ or follow up/
63. versus.tw.
64. prospective.tw.
65. types of study/
66. methodology/
67. comparative study/
68. ((intervention or experiment$) adj5 group$).tw.
69. controls.tw.
70. (controlled adj (stud$ or trial$ or experiment$)).tw.
71. or/46-70
72. 15 and 45 and 71

WHAT’S NEW
Last assessed as up-to-date: 7 December 2004.

Date Event Description

26 August 2008 Amended Converted to new review format.

Interventions for apraxia of speech following stroke (Review) 10

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
HISTORY
Protocol first published: Issue 3, 2003
Review first published: Issue 4, 2005

CONTRIBUTIONS OF AUTHORS
Carolyn West, Audrey Bowen and Andy Vail assisted with obtaining funding from the North West Region NHS Executive, UK.
Carolyn West wrote the protocol and review with the assistance of the other co-authors (Audrey Bowen, Andy Vail, and Anne Hesketh).
Anne Hesketh provided knowledge in the field of apraxia of speech.
The authors represent the following professions.

• Occupational therapy: Carolyn West

• Psychology: Audrey Bowen
• Speech and language therapy: Anne Hesketh
• Medical statistics: Andy Vail

DECLARATIONS OF INTEREST
Audrey Bowen, Anne Hesketh and Andy Vail are investigators for the UK Department of Health trial of aphasia and dysarthria (ACT
NoW Study).

SOURCES OF SUPPORT

Internal sources
• No sources of support supplied

External sources
• North West NHS R&D Executive, UK.

INDEX TERMS

Medical Subject Headings (MeSH)

∗ Speech Therapy; Apraxias [etiology; ∗ therapy]; Articulation Disorders [∗ therapy]; Stroke [∗ complications]

Interventions for apraxia of speech following stroke (Review) 11

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
MeSH check words
Humans

Interventions for apraxia of speech following stroke (Review) 12

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.