Speech Therapy - An Introduction

Speech and language therapists assess and treat speech, language and communication problems in people of all ages. They help people to become independent communicators using speech, gesture and/or communication aids as needed. They also work with people who have eating, drinking, chewing and swallowing difficulties^[1]. They work as part of a multidisciplinary team and have close links with teachers, doctors, nurses, psychologists, occupational therapists and other health professionals. They work in hospital and community settings: on inpatient wards, in outpatient clinics, and in schools, health centres and clients' homes. The NHS Information Centre non-medical census (NHS IC, 2011) recorded a headcount of 7,664 qualified speech and language therapists working in the NHS in England^[2]. Speech and language therapy (SLT) is also available privately, for adults and children, through the Association of Speech and Language Therapists in Independent Practice (ASLTIP).

The scope of the problem

In the UK^[3]:

• 2.5 million people have a speech or language difficulty.
• 5% of children enter school with difficulties in speech and language.
• 30% of people who have had a cerebrovascular event have a persisting speech and language disorder.
• More than 60% of young offenders have some form of speech and language impairment or communication needs.
• Over 75% of people with mental health disorders have communication difficulties.

In the year 2004-2005:

• There were 346,000 initial contacts, or new episodes of care, made by speech and language therapists working in the NHS in England^[4].
• Most of these referrals were made by hospital consultants in general medicine, geriatric medicine and ear, nose and throat specialties.^[4]
• 38% of referrals were for children of preschool or school age^[4].

Increasing demand is likely to result from the ageing population, the rise in dementia and the increasing number of children with complex speech, language and communication needs^[2]. 

Typical patients seen by speech and language therapists^[5]

These include:

• Babies who have problems with feeding and/or swallowing.
• Children with:
  • General learning disability.
  • Physical disability.
  • Language delay.
  • Difficulties in sound production.
  • Hearing problems.
  • Cleft palate.
  • Stammering.
  • Autistic spectrum disorders.
  • Dyslexia.
  • Voice disorders.
  • Selective mutism.
• Adults with:
  • Eating, swallowing and/or communication problems following stroke.
  • Neurological impairment or degenerative conditions such as head injury, Parkinson's disease, motor neurone disease and dementia.
  • Cancer of the head, neck or throat (including laryngectomy).
  • Voice problems.
  • Mental health problems.
  • Learning difficulty.
  • Physical disability.
  • Stammering.
  • Hearing problems. 

Training to become a speech and language therapist^[6]

There is a three- or four-year degree course accredited by the Royal College of Speech and Language Therapists (RCSLT) and graduates are registered by the college. A two-year postgraduate qualification can also be taken if the candidate has an appropriate first degree. All speech and language therapists are registered with the Health and Care Professions Council (HCPC). To be registered, speech and language therapists must meet the Council's standards for their training, professional skills, behaviour and health.

SLT assistants, support workers and bilingual co-workers also exist. These team members work alongside a speech and language therapist, including working with clients on a one-to-one basis, assisting in group therapy sessions, clerical and administrative work or advising on culture and language differences.

The evidence base for speech and language therapy

SLT, like every other aspect of medical care, should be subjected to vigorous scientific appraisal. Trials have been undertaken in the field of SLT. Evidence from large, randomised controlled trials (RCTs) is the gold standard. A review of evidence found the following:

• A Cochrane review, published in 2003, concluded that there was some evidence for the effectiveness of SLT for children with expressive phonological and expressive vocabulary difficulties. It showed that there was mixed evidence for SLT interventions in children with expressive syntax difficulties and that more research was needed concerning interventions for those with receptive language difficulties.^[7]
• A Finnish study found that intensive speech therapy could help some patients who stuttered^[8].
• A Cochrane review published in 2012 showed some indication that SLT for people with aphasia after a stroke is effective. There seemed to be some evidence that people who had intensive SLT may do better, although in the trials reviewed, more people withdrew from intensive SLT than from conventional SLT. Overall, there was insufficient evidence to draw conclusions about the most effective way of delivering SLT^[9].
• Another Cochrane review found that more research is needed to determine the effectiveness of SLT in people with Parkinson's disease who have dysarthria^[10].
• A Cochrane review looking at children with cerebral palsy found no firm evidence of the positive effects of SLT. Again, the authors noted that further research is needed^[11]. Likewise, more evidence is required to support the use of interventions for childhood apraxia of speech and dysarthria associated with acquired brain injury in children and adolescents^{[12, 13]}.

Speech and language therapy after a cerebrovascular event

The incidence of dysphagia has been reported in a variety of studies as being between 40-78%. This may put them at risk of aspiration and pneumonia. Stroke patients can also have speech, language and communication problems^[14].

The National Institute for Health and Care Excellence (NICE) has issued guidelines on the diagnosis and acute management of stroke and transient ischaemic attacks^[15]. Scottish Intercollegiate Guidelines Network (SIGN) has also issued guidelines on the management of patients with stroke, including guidelines about the assessment and management of dysphagia in stroke patients^{[16, 17, 18]}. As well as this, the Intercollegiate Stroke Working Party (ISWP) has issued national clinical guidelines for stroke which incorporate the recommendations from NICE^[14]. All of these guidelines recognise speech and language therapists as an integral part of the stroke care team and give specific details about when a stroke patient should be referred to a speech and language therapist. The ISWP National Clinical Guidelines for Stroke suggest the following:

• On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication. If there are concerns, referral to a speech and language therapist (or other appropriately trained professional with specialism in dysphagia) should be made, preferably within 24 hours of admission and not more than 72 hours afterwards.
• Referral to a speech and language therapist should also be made for any communication difficulties including suspected aphasia, unclear or unintelligible speech affecting a patient's communication, suspected speech apraxia (problems with word articulation) or communication difficulties despite reasonable cognition and language function.

Conclusion

Speech and language therapists and their assistants form an important part of the multidisciplinary team. Their specialist training allows assessment and treatment of patients of all ages with varied and complex medical and developmental problems. They are governed by their own professional standards and guidelines, supported by evidence from the literature and consensus expert opinion.