Background & Objectives: Swallow strength and skill training with surface electromyography (sEMG) biofeedback may improve dysphagia but little is known about the feasibility and efficacy of this intervention in acute stroke. Methods: We conducted a randomized controlled feasibility study in acute stroke patients with dysphagia. Participants were randomized to either usual care or usual care plus swallow strength and skill training with sEMG biofeedback. Primary outcomes were feasibility and acceptability. Secondary measures included swallowing and clinical outcomes, safety and swallow physiology. Results: Twenty-seven patients (13 biofeedback, 14 control) with average age of 73.3 (SD 11.0) and National Institute of Health Stroke Scale (NIHSS) of 10.7 (5.1) were recruited 22.4 (9.5) days post stroke. About 84.6% of participants completed >80% of sessions; failed sessions were mainly due to participant availability, drowsiness or refusal. Sessions lasted for an average of 36.2 (7.4) min. Although 91.7% found the intervention comfortable with satisfactory administration time, frequency and time post stroke, 41.7% found it challenging. There were no treatment-related serious adverse events. The biofeedback group had a lower Dysphagia Severity Rating Scale (DSRS) score at 2 weeks compared to control (3.2 vs. 4.3), but the difference did not reach statistical significance. Conclusions: Swallow strength and skill training with sEMG biofeedback appears feasible and acceptable to acute stroke patients with dysphagia. Preliminary data suggests it is safe and further research refining the intervention and investigating treatment dose and efficacy is warranted.

Abstract: BACKGROUND: Post-stroke aphasia might improve over many years with speech and language therapy; however speech and language therapy is often less readily available beyond a few months after stroke. We assessed self-managed computerised speech and language therapy (CSLT) as a means of providing more therapy than patients can access through usual care alone. METHODS: In this pragmatic, superiority, three-arm, individually randomised, single-blind, parallel group trial, patients were recruited from 21 speech and language therapy departments in the UK. Participants were aged 18 years or older and had been diagnosed with aphasia post-stroke at least 4 months before randomisation; they were excluded if they had another premorbid speech and language disorder caused by a neurological deficit other than stroke, required treatment in a language other than English, or if they were currently using computer-based word-finding speech therapy. Participants were randomly assigned (1:1:1) to either 6 months of usual care (usual care group), daily self-managed CSLT plus usual care (CSLT group), or attention control plus usual care (attention control group) with the use of computer-generated stratified blocked randomisation (randomly ordered blocks of sizes three and six, stratified by site and severity of word finding at baseline based on CAT Naming Objects test scores). Only the outcome assessors and trial statistician were masked to the treatment allocation. The speech and language therapists who were doing the outcome assessments were different from those informing participants about which group they were assigned to and from those delivering all interventions. The statistician responsible for generating the randomisation schedule was separate from those doing the analysis. Co-primary outcomes were the change in ability to retrieve personally relevant words in a picture naming test (with 10% mean difference in change considered a priori as clinically meaningful) and the change in functional communication ability measured by masked ratings of video-recorded conversations, with the use of Therapy Outcome Measures (TOMs), between baseline and 6 months after randomisation (with a standardised mean difference in change of 0·45 considered a priori as clinically meaningful). Primary analysis was based on the modified intention-to-treat (mITT) population, which included randomly assigned patients who gave informed consent and excluded those without 6-month outcome measures. Safety analysis included all participants. This trial has been completed and was registered with the ISRCTN, number ISRCTN68798818. FINDINGS: From Oct 20, 2014, to Aug 18, 2016, 818 patients were assessed for eligibility, of which 278 (34%) participants were randomly assigned (101 [36%] to the usual care group; 97 [35%] to the CSLT group; 80 [29%] to the attention control group). 86 patients in the usual care group, 83 in the CSLT group, and 71 in the attention control group contributed to the mITT. Mean word finding improvements were 1·1% (SD 11·2) in the usual care group, 16·4% (15·3) in the CSLT group, and 2·4% (8·8) in the attention control group. Word finding improvement was 16·2% (95% CI 12·7 to 19·6; p<0·0001) higher in the CSLT group than in the usual care group and was 14·4% (10·8 to 18·1) higher than in the attention control group. Mean changes in TOMs were 0·05 (SD 0·59) in the usual care group (n=84), 0·04 (0·58) in the CSLT group (n=81), and 0·10 (0·61) in the attention control group (n=68); the mean difference in change between the CSLT and usual care groups was -0·03 (-0·21 to 0·14; p=0·709) and between the CSLT and attention control groups was -0·01 (-0·20 to 0·18). The incidence of serious adverse events per year were rare with 0·23 events in the usual care group, 0·11 in the CSLT group, and 0·16 in the attention control group. 40 (89%) of 45 serious adverse events were unrelated to trial activity and the remaining five (11%) of 45 serious adverse events were classified as unlikely to be related to trial activity. INTERPRETATION: CSLT plus usual care resulted in a clinically significant improvement in personally relevant word finding but did not result in an improvement in conversation. Future studies should explore ways to generalise new vocabulary to conversation for patients with chronic aphasia post-stroke. FUNDING: National Institute for Health Research, Tavistock Trust for Aphasia.

Intrauterine contraception is used by about 100 million women worldwide, making it the most popular form of fertility regulation. In UK community contraception clinics, however, long-acting reversible contraception has increased to 28% of users, and intrauterine contraception accounts for only 8% of methods used by women accessing these services. Potential exists to increase uptake of these more effective methods. In this chapter, we review the clinical advantages, disadvantages and cost-effectiveness of intrauterine contraception. We discuss the management of complications along with advice for trainers, and briefly consider issues in developing countries.

BACKGROUND: Speech and language therapy provision for aphasia (a language disorder) post stroke has been studied over time through surveys completed by speech and language therapists. This paper revisits provision based on what was received by 278 patients in 21 UK speech and language therapy departments in 2014-2016. AIMS: To explore the speech and language therapy received by community dwelling people with post stroke aphasia in the UK. METHODS AND PROCEDURES: A quantitative content analysis was conducted by two speech and language therapist researchers. Therapy goals recorded were coded into categories and subcategories. Descriptive statistics were used to identify the frequency with which goal categories were targeted, average therapy time received, length and frequency of therapy sessions, personnel involved and mode of delivery. OUTCOMES AND RESULTS: Forty-five percent of participants were in receipt of therapy in the three month window observed. Six goal categories were identified. Rehabilitation was the most frequent (60%) followed by enabling (17.2%), review (4.3%), assessment (3.6%), supportive (3.5%) and activity to support therapy (2.8%). The median amount of therapy received in three months was 6.3 hours at an average of one 60-minute session every two weeks. Seventy-seven percent of therapy sessions were delivered by qualified speech and language therapists and 23% by assistants. Ninety percent of sessions were one to one, face to face sessions whilst 9.5% were group sessions. DISCUSSION: In line with previous reports, speech and language therapy for community dwelling stroke survivors with aphasia is restricted. Rehabilitation is a large focus of therapy but the intensity and dose with which it is provided is substantially lower than that required for an effective outcome. Despite this, one to one face to face therapy is favoured. More efficient methods to support more therapeutic doses of therapy are not commonly used in routine clinical services.