The efficacy of group communication treatment in adults with chronic aphasia

Attention control comparisons with SLT for people with aphasia following stroke: methodological concerns raised following a systematic review

Objective:

Attention control comparisons in trials of stroke rehabilitation require care to minimize the risk of comparison choice bias. We compared the similarities and differences in SLT and social support control interventions for people with aphasia.

Data sources:

Trial data from the 2016 Cochrane systematic review of SLT for aphasia after stroke

Methods:

Direct and indirect comparisons between SLT, social support and no therapy controls. We double-data extracted intervention details using the template for intervention description and replication. Standardized mean differences and risk ratios (95% confidence intervals (CIs)) were calculated.

Results:

Seven trials compared SLT with social support ( n  =  447). Interventions were matched in format, frequency, intensity, duration and dose. Procedures and materials were often shared across interventions. Social support providers received specialist training and support. Targeted language rehabilitation was only described in therapy interventions. Higher drop-out ( P  =  0.005, odds ratio (OR) 0.51, 95% CI 0.32–0.81) and non-adherence to social support interventions ( P  <  0.00001, OR 0.18, 95% CI 0.09–0.37) indicated an imbalance in completion rates increasing the risk of control comparison bias.

Conclusion:

Distinctions between social support and therapy interventions were eroded. Theoretically based language rehabilitation was the remaining difference in therapy interventions. Social support is an important adjunct to formal language rehabilitation. Therapists should continue to enable those close to the person with aphasia to provide tailored communication support, functional language stimulation and opportunities to apply rehabilitation gains. Systematic group differences in completion rates is a design-related risk of bias in outcomes observed.

Aphasia As a Predictor of Stroke Outcome

PURPOSE OF REVIEW

Aphasia is a common feature of stroke, affecting 21-38% of acute stroke patients and an estimated 1 million stroke survivors. Although stroke, as a syndrome, is the leading cause of disability in the USA, less is known about the independent impact of aphasia on stroke outcomes.

RECENT FINDINGS

During the acute stroke period, aphasia has been found to increase length of stay, inpatient complications, overall neurological disability, mortality, and to alter discharge disposition. Outcomes during the sub-acute and chronic stroke periods show that aphasia is associated with lower Functional Independence Measures (FIM) scores, longer stays in rehabilitation settings, poorer function in activities of daily living, and mortality. Factors that complicate the analysis of aphasia on post-stroke outcomes, however, include widely different systems of care across international settings that result in varying admission patterns to acute stroke units, allowable length of stays based on reimbursement, and criteria for rehabilitation placement. Aphasia arising from stroke is associated with worse outcomes both in the acute and chronic periods. Future research will have to incorporate disparate patterns in analytic models, and to take into account specific aphasia profiles and evolving methods of post-stroke speech-language therapy.

Priorities for Closing the Evidence-Practice Gaps in Poststroke Aphasia Rehabilitation: A Scoping Review

OBJECTIVE

To identify implementation priorities for poststroke aphasia management relevant to the Australian health care context.

DATA SOURCES

Using systematized searches of databases (CINAHL and MEDLINE), guideline and stroke websites, and other sources, evidence was identified and extracted for 7 implementation criteria for 13 topic areas relevant to aphasia management. These 7 priority-setting criteria were identified in the implementation literature: strength of the evidence, current evidence-practice gap, clinician preference, patient preference, modifiability, measurability, and health effect.

STUDY SELECTION

Articles were included if they were in English, related to a specific recommendation requiring implementation, and contained information pertaining to any of the 7 prioritization criteria.

DATA EXTRACTION

The scoping review methodology was chosen to address the broad nature of the topic. Evidence was extracted and placed in an evidence matrix. After this, evidence was summarized and then aphasia rehabilitation topics were prioritized using an approach developed by the research team.

DATA SYNTHESIS

Evidence from 100 documents was extracted and summarized. Four topic areas were identified as implementation priorities for aphasia: timing, amount, and intensity of therapy; goal setting; information, education, and aphasia-friendly information; and constraint-induced language therapy.

CONCLUSIONS

Closing the evidence-practice gaps in the 4 priority areas identified may deliver the greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to developing implementation priorities may be useful for identifying priorities for implementation in other health care areas.

Does Naming Therapy Make Ordering in a Restaurant Easier? Dynamics of Co-Occurring Change in Cognitive-Linguistic and Functional Communication Skills in Aphasia

PURPOSE

This study was conducted to investigate the static and dynamic relationships between impairment-level cognitive-linguistic abilities and activity-level functional communication skills in persons with aphasia (PWA).

METHOD

In Experiment 1, a battery of standardized assessments was administered to a group of PWA (N = 72) to examine associations between cognitive-linguistic ability and functional communication at a single time point. In Experiment 2, impairment-based treatment was administered to a subset of PWA from Experiment 1 (n = 39) in order to examine associations between change in cognitive-linguistic ability and change in function and associations at a single time point.

RESULTS

In both experiments, numerous significant associations were found between scores on tests of cognitive-linguistic ability and a test of functional communication at a single time point. In Experiment 2, significant treatment-induced gains were seen on both types of measures in participants with more severe aphasia, yet cognitive-linguistic change scores were not significantly correlated with functional communication change scores.

CONCLUSIONS

At a single time point, cognitive-linguistic and functional communication abilities are associated in PWA. However, although changes on standardized assessments reflecting improvements in both types of skills can occur following an impairment-based therapy, these changes may not be significantly associated with each other.

Comparing linguistic complexity and efficiency in conversations from stimulation and conversation therapy in aphasia

BACKGROUND

Efficacy studies have demonstrated the benefit of group conversation therapy for a person with aphasia (PWA). However, a PWA typically participates in individual therapy prior to group therapy. Stimulation therapy (ST) is the most common type of individual aphasia therapy. Ultimately, the outcome of therapy is to enable the PWA to communicate effectively with others, which suggests the need for conversation therapy (CT). Little efficacy data exist to demonstrate the benefit of CT between a PWA and a clinician, in part because no clear treatment outcome measures have been established. More information is needed to identify optimal ways to measure CT outcomes.

AIM

To identify ways to measure CT outcomes and to determine if there is a change in linguistic complexity and total talk time during conversation, samples were taken during CT and ST in two PWAs.

METHODS & PROCEDURES

Seventeen 6-min conversational samples per PWA were analyzed from a prior single-subject AB₁ AB₂ A alternating treatment study with randomized ordering of interventions across participants. Data were analyzed for seven measures of linguistic complexity using Systematic Analysis of Language Transcripts (SALT). Efficiency was measured using correct information units (CIUs) per minute and total talk time.

OUTCOMES & RESULTS

Per cent of complex utterances and propositional density were higher following CT. Four out of seven linguistic measures increased following ST. Total talk time was significantly greater for one PWA during CT compared with ST. No differences were found in CIUs/min across treatment types.

CONCLUSION & IMPLICATIONS

Linguistic complexity and efficiency appear to be conversational treatment outcome measures that are sensitive to change, which researchers might consider using.

Effect of aphasia on acute stroke outcomes

OBJECTIVE

To determine the independent effects of aphasia on outcomes during acute stroke admission, controlling for total NIH Stroke Scale (NIHSS) scores and loss of consciousness.

METHODS

Data from the Tulane Stroke Registry were used from July 2008 to December 2014 for patient demographics, NIHSS scores, length of stay (LOS), complications (sepsis, deep vein thrombosis), and discharge modified Rankin Scale (mRS) score. Aphasia was defined as a score >1 on question 9 on the NIHSS on admission and hemiparesis as >1 on questions 5 or 6.

RESULTS

Among 1,847 patients, 866 (46%) had aphasia on admission. Adjusting for NIHSS score and inpatient complications, those with aphasia had a 1.22 day longer LOS than those without aphasia, whereas those with hemiparesis (n = 1,225) did not have any increased LOS compared to those without hemiparesis. Those with aphasia had greater odds of having a complication (odds ratio [OR] 1.44, confidence interval [CI] 1.07-1.93, p = 0.0174) than those without aphasia, which was equivalent to those having hemiparesis (OR 1.47, CI 1.09-1.99, p = 0.0137). Controlling for NIHSS scores, aphasia patients had higher odds of discharge mRS 3-6 (OR 1.42 vs 1.15).

CONCLUSION

Aphasia is independently associated with increased LOS and complications during the acute stroke admission, adding $2.16 billion annually to US acute stroke care. The presence of aphasia was more likely to produce a poor functional outcome than hemiparesis. These data suggest that further research is necessary to determine whether establishing adaptive communication skills can mitigate its consequences in the acute stroke setting.

Aphasia rehabilitation during adolescence: a case report

PURPOSE

Descriptions of speech-language interventions addressing the unique aspects of aphasia in adolescence appear to be nonexistent. The current paper presents the case of a male adolescent who experienced a stroke with resultant aphasia and the speech and language therapy he received. Furthermore, we discuss the issues that are unique to an adolescent with aphasia and how they were addressed with this particular patient.

METHODS

Traditional language and apraxia therapy was provided to this patient with inclusion of technology and academic topics.

RESULTS

The patient demonstrated improvements in his speech and language abilities, most notably his reading comprehension and speech production. Age-related issues, including academic needs, group treatment, socialization, adherence/compliance, independence and family involvement, emerged during intervention.

CONCLUSION

Although aphasia therapy for adolescents may be similar in many aspects to selected interventions for adults, it is necessary for the clinician to be mindful of age-related issues throughout the course of therapy. Goals and interventions should be selected based on factors salient to an adolescent as well as the potential long-term impact of therapy. Implications for Research Aphasia and its treatment in adolescence need to be further explored. Academics and technology are important aspects of aphasia treatment in adolescence. Issues specific to adolescence such as socialization, adherence/compliance, and independence are important to address in speech-language therapy.

Restoring one's language edifice: A case study of long-term effects of intensive aphasia therapy employing cognitive modifiability strategies

NG is an architect who suffered a left occipital-parietal hemorrhage cerebral vascular accident (CVA) in 2000, resulting in aphasia of Wernicke and conduction types. He was characterized with fluent paraphasic speech, decreased repetition, and impaired object naming. Comprehension was relatively preserved but reading and writing were severely compromised, as well as his auditory working memory. Despite a grim prognosis he underwent intensive aphasia therapy, lasting from 2001 to 2010, at the Center for Cognitive Rehabilitation of the Brain Injured at the Feuerstein Institute. The tailored-made interventions, applied in NG's therapy, were based upon the implementation of the principles of the Structural Mediated Learning Experience (MLE) and the Feuerstein Instrumental Enrichment (FIE) Program, to optimize his rehabilitation. As a result NG improved in most of his impaired linguistic capacities, attested by the results of neuropsychological and linguistic assessments performed throughout the years. More importantly, he was able to manage again his daily functions at a high level, and to resume his occupational role as an architect, a role which he holds to this day.

Speech and language therapy for aphasia following stroke

BACKGROUND

Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and writing. Approximately one third of people who have a stroke experience aphasia.

OBJECTIVES

To assess the effects of speech and language therapy (SLT) for aphasia following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015), MEDLINE (1946 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), AMED (1985 to September 2015), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015). We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015), the Stroke Trials Registry (to 21 September 2015), Current Controlled Trials (to 22 September 2015), and WHO ICTRP (to 22 September 2015). In an effort to identify further published, unpublished, and ongoing trials we also handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles, and we contacted academic institutions and other researchers. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) versus no SLT; social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); or another SLT intervention (differing in duration, intensity, frequency, intervention methodology or theoretical approach).

DATA COLLECTION AND ANALYSIS

We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.

MAIN RESULTS

We included 57 RCTs (74 randomised comparisons) involving 3002 participants in this review (some appearing in more than one comparison). Twenty-seven randomised comparisons (1620 participants) assessed SLT versus no SLT; SLT resulted in clinically and statistically significant benefits to patients' functional communication (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.49, P = 0.01), reading, writing, and expressive language, but (based on smaller numbers) benefits were not evident at follow-up. Nine randomised comparisons (447 participants) assessed SLT with social support and stimulation; meta-analyses found no evidence of a difference in functional communication, but more participants withdrew from social support interventions than SLT. Thirty-eight randomised comparisons (1242 participants) assessed two approaches to SLT. Functional communication was significantly better in people with aphasia that received therapy at a high intensity, high dose, or over a long duration compared to those that received therapy at a lower intensity, lower dose, or over a shorter period of time. The benefits of a high intensity or a high dose of SLT were confounded by a significantly higher dropout rate in these intervention groups. Generally, trials randomised small numbers of participants across a range of characteristics (age, time since stroke, and severity profiles), interventions, and outcomes.

AUTHORS' CONCLUSIONS

Our review provides evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, reading, writing, and expressive language compared with no therapy. There is some indication that therapy at high intensity, high dose or over a longer period may be beneficial. HIgh-intensity and high dose interventions may not be acceptable to all.

Group therapy as a social context for aphasia recovery: a pilot, observational study in an acute rehabilitation hospital

BACKGROUND

Individuals with aphasia often receive therapy from a speech-language pathologist during acute rehabilitation. The literature demonstrates that group-based therapy provides a natural, social environment for language rehabilitation in mild-moderate and/or chronic aphasia; however, the communication of persons with acute, severe non-fluent aphasia during group treatment has not been fully explored.

OBJECTIVE

This observational study investigated patient communication during acute rehabilitation. The primary objective was to determine whether participants initiate more communication during group therapy sessions when compared to individual therapy sessions.

METHOD

Ten participants with severe non-fluent aphasia were observed during one individual and one group session during their stay in an acute, inpatient rehabilitation facility. Communicative initiations were tallied and categorized based on type, target, and purpose.

RESULTS

Participants initiated communication more often during group sessions than during individual sessions. During groups, participants used more vocalizations and facial expressions to communicate, and the purpose was more often for social closeness than in individual sessions. Participants produced fewer different, real words in group vs. individual sessions, but other measures of communication skill did not differ significantly between the two settings.

CONCLUSION

In the aphasia group treatment described in this study, participants initiated more communication, with greater diversity of expressive modalities and more varied communicative purposes. Participants in group therapy also showed an increased tendency to communicate for the purpose of social closeness. These findings suggest that there are important differences in the communication of patients participating in group vs. individual speech therapy for treatment of acute, severe non-fluent aphasia.

Organizational context associated with time spent evaluating language and cognitive-communicative impairments in skilled nursing facilities: Survey results within an implementation science framework

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR) was developed to merge research and practice in healthcare by accounting for the many elements that influence evidence-based treatment implementation. These include characteristics of the individuals involved, features of the treatment itself, and aspects of the organizational culture where the treatment is being provided.

AIMS

The purpose of this study was to apply the CFIR to a measurement of current practice patterns of speech-language pathologists (SLPs) working in the skilled nursing facility (SNF) environment. In an effort to inform future evidence-based practice implementation interventions, research questions addressed current practice patterns, clinician treatment use and preferences, and perceptions of the organizational context including leadership, resources, and other staff.

METHODS AND PROCEDURES

Surveys were mailed to each SLP working in a SNF in the state of Michigan. Participants (N=77, 19% response rate) completed a survey mapping on to CFIR components impacting evidence-based practice implementation. Quantitative descriptive and nonparametric correlational analyses were completed.

OUTCOMES AND RESULTS

Use of evidence-based treatments by SLPs in SNFs was highly variable. Negative correlations between treating speech and voice disorders and treating swallowing disorders (rs=-.35, p<.01), evaluating language and cognitive-communicative disorders and treating swallowing disorders (rs=-.30, p<.01), treating language and cognitive-communicative disorders and treating swallowing disorders (rs=-.67, p<.01), and evaluating swallowing disorders and treating language and cognitive-communicative disorders (rs=-.37, p<.01) were noted. A positive correlation between the SLPs' perception of organizational context and time spent evaluating language and other cognitive-communicative disorders (rs=.27, p<.05) was also present.

CONCLUSIONS

Associative data suggest that the more an SLP in the SNF evaluates and treats swallowing disorders, the less he or she will evaluate speech, voice, language or other cognitive-communicative disorders. Further, SLPs in this sample spent more time evaluating language and cognitive-communicative impairments if they perceived their organizational context in a more positive way. The CFIR may guide treatment and implementation research to increase the uptake of evidence-based practices for SLPs working in the SNF setting.

Management of Communication Disorders Using Family Member Input, Group Treatment, and Telerehabilitation

Today, speech-language pathologists (SLPs) practice stroke rehabilitation in environments where they have less time to manage the communication impairments of patients who are more medically fragile than ever before. Many SLPs have creatively adapted their practice to maximize functional outcomes for their patients. This article highlights three techniques designed to enhance functional SLP outcomes: maximizing family member input; providing group treatment; and providing treatment in remote, functional settings via telepractice technology.

Combining Teletherapy and On-line Language Exercises in the Treatment of Chronic Aphasia: An Outcome Study

We report a 12-week outcome study in which nine persons with long-term chronic aphasia received individual and group speech-language teletherapy services, and also used on-line language exercises to practice from home between therapy sessions. Participants were assessed at study initiation and completion using the Western Aphasia Battery, a portion of the Communicative Effectiveness Index, ASHA National Outcome Measurement System, and RIC Communication Confidence Rating Scale for Aphasia; additionally participants were polled regarding satisfaction at discharge. Pretreatment and post-treatment means were calculated and compared, and matched t-tests were used to determine significance of improvements following treatment, with patterns of independent on-line activity analyzed. Analysis of scores shows that means improved on most measures following treatment, generally significantly: the WAB AQ improved +3.5 (p = .057); the CETI Overall (of items administered) - +17.8 (p = .01), and CCRSA Overall - + 10.4 (p = .0004). Independent work increased with time, and user satisfaction following participation was high.

Conversation therapy for aphasia: a qualitative review of the literature

BACKGROUND

A diverse literature addresses elements of conversation therapy in aphasia including intervention rooted in conversation analysis, partner training, group therapy and behavioural intervention. Currently there is no resource for clinicians or researchers that defines and organizes this information into a coherent synopsis describing various conversation therapy practices.

AIMS

To organize information from varied sources into a descriptive overview of conversation therapy for aphasia.

METHODS & PROCEDURES

Academic search engines were employed to identify research articles published between 1950 and September 2013 reporting on conversation therapy for aphasia. Thirty articles met criteria for review and were identified as primary sources for the qualitative review. Using qualitative methodology, relevant data were extracted from articles and categories were identified to create a descriptive taxonomy of conversation therapy for aphasia.

MAIN CONTRIBUTION

Conversation interventions were divided into descriptive categories including: treatment participants (person with aphasia, partner, dyad), primary guiding orientation (conversation analysis, social model, behavioural, relationship centred), service delivery (individual, group), focus of intervention (generic/individualized; problem/solution oriented; compensatory), training methods (explicit/implicit; external/embedded), activities or tasks, and outcomes measured. Finally, articles were categorized by research design. There was marked variation in conversation therapy approaches and outcome measures reported and a notable gap in information about one-on-one conversation therapy for individuals with aphasia.

CONCLUSIONS & IMPLICATIONS

This review provides a description of various conversation therapy approaches and identified gaps in the existing literature. Valid measures of natural conversation, research on one-on-one conversation approaches for individuals with aphasia, and a systematic body of evidence consisting of high quality research are needed.

Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting

The current study explored the clinical feasibility and costs of embedding three different intensive service delivery models for aphasia treatment (computer, group therapy, and therapy with a speech pathology therapy assistant) within three sub-acute facilities. The study employed a two cohort comparison design, with the first cohort (n = 22) receiving the standard service of treatment currently offered. This treatment was delivered by a speech-language pathologist and involved on average 3 hours of treatment/week over 8 weeks. Participants in the second cohort (n = 31) received one of the three intensive treatment models providing up to 9 hours of therapy/week for 11 weeks. Organizational data was collected throughout treatment, with participant, caregiver, and clinician satisfaction with the intensive models also being measured. Participants completed the spoken language production sub-tests and the Disability Questionnaire of the Comprehensive Aphasia Test (CAT) pre- and post-treatment. All intensive models yielded high participant attendance, satisfaction, and significant improvements to the CAT sub-tests. The pro-rata cost of providing treatment per hour per client for the computer and group therapy models was found to be ˜ 30% cheaper compared to the standard service. The outcomes support the potential feasibility of embedding the different models into sub-acute facilities to enhance client access to intensive treatment for aphasia.

Integrated training for aphasia: an application of part-whole learning to treat lexical retrieval, sentence production, and discourse-level communications in three cases of nonfluent aphasia

PURPOSE

The purpose of this study was to evaluate integrated training for aphasia (ITA), a multicomponent language-production treatment based on part-whole learning that systematically trains lexical retrieval, sentence production, and discourse-level communications. Specific research objectives were to evaluate acquisition of target structures, statistical parameters associated with learning variables, treatment generalization, and the efficacy of individual treatment components.

METHOD

ITA was administered to 3 individuals with nonfluent aphasia following a multiple-baseline, across-behaviors design. Effect size and correlational coefficients were computed to assess acquisition, generalization, and maintenance of target structures. Standardized tests and a treatment efficacy questionnaire were also completed.

RESULTS

A significant treatment effect was found in 2 of the 3 participants. In addition, as is seen in normal skill acquisition, practice time and error rate were significantly correlated. All participants demonstrated evidence of generalization on standardized language measures. Only 1 participant improved, however, on the communication measures. Results of the treatment component analysis revealed significant differences in the perceived efficacy of individual therapy tasks.

CONCLUSIONS

Findings add to the evidence supporting multicomponent aphasia treatments, provide preliminary support for ITA and the application of a part-whole learning approach, and suggest that specific treatment components may contribute differentially to outcomes and generalization effects.

Description of an intensive residential aphasia treatment program: rationale, clinical processes, and outcomes

PURPOSE

The purpose of this article is to describe the rationale, clinical processes, and outcomes of an intensive comprehensive aphasia program (ICAP).

METHOD

Seventy-three community-dwelling adults with aphasia completed a residentially based ICAP. Participants received 5 hr of daily 1:1 evidence-based cognitive-linguistically oriented aphasia therapy, supplemented with weekly socially oriented and therapeutic group activities over a 23-day treatment course. Standardized measures of aphasia severity and communicative functioning were obtained at baseline, program entry, program exit, and follow-up. Results were analyzed using a Bayesian latent growth curve model with 2 factors representing (a) the initial level and (b) change over time, respectively, for each outcome measure.

RESULTS

Model parameter estimates showed reliable improvement on all outcome measures between the initial and final assessments. Improvement during the treatment interval was greater than change observed across the baseline interval, and gains were maintained at follow-up on all measures.

CONCLUSIONS

The rationale, clinical processes, and outcomes of a residentially based ICAP have been described. ICAPs differ with respect to treatments delivered, dosing parameters, and outcomes measured. Specifying the defining components of complex interventions, establishing their feasibility, and describing their outcomes are necessary to guide the development of controlled clinical trials.

The efficacy of outpatient and community-based aphasia group interventions: a systematic review

This paper examines the evidence for community and outpatient aphasia groups using the International Classification of Functioning, Disability and Health (ICF) framework. A systematic search of the literature using eight electronic databases was completed; 29 studies met inclusion and exclusion criteria. Level of evidence and methodological quality was assessed and effect sizes calculated where possible. Evidence favouring community and outpatient groups centred on four level ii and level iii-i studies that examined the efficacy of highly structured group activities for improving specific linguistic processes with five medium-large effect sizes calculated. Medium and large effect sizes were also calculated on a level iii-i study examining number of friendships and community access. No effect sizes were available for level ii or level iii studies examining communication activity and participation. Overall, the results indicate that community and outpatient group participation can improve specific linguistic processes. There is also some evidence that group participation can benefit social networks and community access. However, there is limited evidence demonstrating improvement in functional communication as a consequence of group participation. The current evidence is not comprehensive. Further well-designed studies, particularly examining activity and participation, and contextual factors are required to advance community and outpatient aphasia group practice and participation.

When does Stroke Rehabilitation End?

This article examines key evidence on intervention effectiveness late poststroke; provides discussion on how this evidence impacts stroke rehabilitation at a clinical and national level; and explores strategies that should improve the way in which chronic stroke is addressed internationally.

Online collaboration environments in telemedicine applications of speech therapy

The use of telemedicine in speech and language pathology provides patients in rural and remote areas with access to quality rehabilitation services that are sufficient, accessible, and user-friendly leading to new possibilities in comprehensive and long-term, cost-effective diagnosis and therapy. This paper discusses the use of online collaboration environments for various telemedicine applications of speech therapy which include online group speech therapy scenarios, multidisciplinary clinical consulting team, and online mentoring and continuing education.

Speech and language therapy for aphasia following stroke

BACKGROUND

Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading and writing. Approximately one-third of people who have a stroke experience aphasia.

OBJECTIVES

To assess the effectiveness of speech and language therapy (SLT) for aphasia following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched June 2011), MEDLINE (1966 to July 2011) and CINAHL (1982 to July 2011). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles and contacted academic institutions and other researchers. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) with (1) no SLT; (2) social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); and (3) another SLT intervention (which differed in duration, intensity, frequency, intervention methodology or theoretical approach).

DATA COLLECTION AND ANALYSIS

We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.

MAIN RESULTS

We included 39 RCTs (51 randomised comparisons) involving 2518 participants in this review. Nineteen randomised comparisons (1414 participants) compared SLT with no SLT where SLT resulted in significant benefits to patients' functional communication (standardised mean difference (SMD) 0.30, 95% CI 0.08 to 0.52, P = 0.008), receptive and expressive language. Seven randomised comparisons (432 participants) compared SLT with social support and stimulation but found no evidence of a difference in functional communication. Twenty-five randomised comparisons (910 participants) compared two approaches to SLT. There was no indication of a difference in functional communication. Generally, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.

AUTHORS' CONCLUSIONS

Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. However, some trials were poorly reported. The potential benefits of intensive SLT over conventional SLT were confounded by a significantly higher dropout from intensive SLT. More participants also withdrew from social support than SLT interventions. There was insufficient evidence to draw any conclusion regarding the effectiveness of any one specific SLT approach over another.

Evidence-based cognitive rehabilitation after acquired brain injury: a systematic review of content of treatment

We reviewed all randomised trials on cognitive rehabilitation in order to determine the effective elements in terms of patients' and treatment characteristics, treatment goals and outcome. A total of 95 random controlled trials were included from January 1980 until August 2010 studying 4068 patients in total. Most studies had been conducted on language (n = 25), visuospatial functioning (n = 24), and memory (n = 14). Stroke patients were the commonest subjects (57%; overall mean age = 52.2, SD = 15.0 years). Of the interventions 39% were offered more than 12 months after onset and 23% were offered within two months of onset. The mean (SD) number of hours of treatment actually delivered was 4.1 (3.6) per week; treatment was mostly offered individually. No papers gave specific information on the expertise or competences of the staff involved. With 95 RCTs there is a large body of evidence to support the efficacy of cognitive rehabilitation, and the current study can serve as a database for clinicians and researchers. But most studies have given little information about the actual content of the treatment which makes it difficult to use the studies when making treatment decisions in daily clinical practice. We suggest developing an international checklist to make standardised description of non-pharmacological complex interventions possible.

Living successfully with aphasia: a qualitative meta-analysis of the perspectives of individuals with aphasia, family members, and speech-language pathologists

The concept of living successfully with aphasia has recently emerged as an alternative to more traditional "deficit" models in aphasiology, encouraging a focus on positive rather than negative outcomes. This research aimed to integrate findings from studies exploring the perspectives of three participant groups (individuals with aphasia, speech-language pathologists, and family members) about living successfully with aphasia. Qualitative meta-analysis of three studies conducted by the authors was used to integrate perspectives across the participant groups. Steps in the qualitative meta-analysis were based on those described in the process of "meta-ethnography" by Noblit and Hare (1988) . Analysis was an inductive process, in which data from each study were re-analysed and translated into each other in order to identify higher-level overarching themes that accounted for similarities and discrepancies across the original studies. A total of seven overarching themes related to living successfully with aphasia were identified. These were: participation, meaningful relationships, support, communication, positivity, independence and autonomy, and living successfully with aphasia as a journey over time. Findings indicate the need for a holistic, client-centred approach that considers communication in the broader context of an individual's daily life. The overarching themes may act as guides for areas of importance to be addressed in clinical practice, as well as in future research. By working in partnership with individuals with aphasia and their families, speech-language pathologists are challenged to continue to improve services and assist clients on their journey of living successfully with aphasia.

An exploration of participant experience of a communication training program for people with traumatic brain injury and their communication partners

PURPOSE

To investigate the experiences of participants who attended communication training programs for people with traumatic brain injury (TBI) and their everyday communication partners (CP) as part of a non-randomised controlled trial.

METHOD

The participants were people with TBI and their CP, who were family members or carers of the people with TBI. Twenty-six participants (13 participants with TBI and 13 CP) completed the JOINT program, which involved participants with TBI and CP attending the program together. Fourteen participants with TBI completed the TBI SOLO training program, which did not involve the participation of a CP. Semi-structured videotaped interviews were completed by all participants at the end of the training. Using a six-step generic analysis procedure, data were categorised into topics and then subtopics to identify conceptually discrete units.

RESULTS

Participants described improvements in communication skills, the impact of improved communication skills, valuable components of the programs and components that needed changes.

CONCLUSION

The accounts of participants provided additional evidence for the effectiveness of the training programs, assisted with identifying helpful components of the training and demonstrated the usefulness of a qualitative research methodology as part of evaluating the outcomes of the clinical trial.

Is Aphasia Therapy Effective? Exploring the Evidence in Systematic Reviews

In December 1999, Greener, Enderby and Whurr reported the findings of their Cochrane review to assess the effects of formal speech and language therapy for people with aphasia following stroke. They concluded that aphasia therapy had not been shown to be “clearly effective or clearly ineffective within a randomised controlled trial (RCT)” (p. 1). Their conclusion led to much discussion among speech pathologists with some expressing grave concern that the outcome of the review would undermine the provision of services for people with aphasia and their carers. In this paper, evidence for the effectiveness of aphasia therapy that has been provided by published systematic reviews is critically explored. Clearly, challenges remain with respect to provision of evidence-based aphasia therapy. However, the weight of evidence accumulated over the years and synthesised in systematic reviews supports the broad conclusion that aphasia therapy is effective.

The Impact of Varied Speaker Role and Communication Partner on the Communicative Interactions of a Person With Traumatic Brain Injury: A Single Case Study Using Systemic Functional Linguistics

This article presents preliminary findings on an investigation into the differences in communicative performance across varying speaking conditions, of an individual with a cognitive–linguistic impairment following traumatic brain injury (TBI). The article compares the communicative exchanges of an individual in a conversation with a therapist, a conversational dyad with a peer with TBI, and in a communication group task where they were interacting with other participants with TBI. The speaking conditions studied included an unstructured chat, the participant requesting information and the participant giving information. Results showed that the person with TBI responded to differences in communication partner and speaker role. He was best able to give information in the unstructured chat with the clinician and the information giving session in the group. Requesting was maximally facilitated in the information request condition with the clinician. Qualitatively, however, the most equal interactions occurred with the peer, with evidence of the person with TBI engaging in typical conversational strategies such as establishing common ground to facilitate topic development and co-constructing the discourse topics. These strategies did not occur in the clinician or group interactions, possibly due to power imbalance in the former and impaired cognitive–linguistic ability in the latter situation. Implications for clinical decision making regarding intervention strategies for patients with cognitive–communication deficits are discussed.

Statistical, practical, clinical, and personal significance: definitions and applications in speech-language pathology

PURPOSE

To discuss constructs and methods related to assessing the magnitude and the meaning of clinical outcomes, with a focus on applications in speech-language pathology.

METHOD

Professionals in medicine, allied health, psychology, education, and many other fields have long been concerned with issues referred to variously as practical significance, clinical significance, social validity, patient satisfaction, treatment effectiveness, or the meaningfulness or importance of beyond-clinic or real-world treatment outcomes. Existing literature addressing these issues from multiple disciplines was reviewed and synthesized.

CONCLUSIONS

Practical significance, an adjunct to statistical significance, refers to the magnitude of a change or a difference between groups. The appropriate existing term for the interpretation of treatment outcomes, or the attribution of meaning or value to treatment outcomes, is clinical significance. To further distinguish between important constructs, the authors suggest incorporating as definitive the existing notion that clinical significance may refer to measures selected or interpreted by professionals or with respect to groups of clients. The term personal significance is introduced to refer to goals, variables, measures, and changes that are of demonstrated value to individual clients.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Applying the correlation between aphasia severity and quality of life measures to a life participation approach to aphasia

When clinicians are operating under a Life Participation Approach to Aphasia (LPAA) while treating persons with aphasia (PWAs), one measurement used to quantify outcomes is quality of life (QOL). Studies of QOL after stroke have identified multiple factors as cause agents. There is not an extensive body of research in the literature that compares the extent of aphasia and QOL and no literature as to how this applies in an LPAA. This article reports a comparison of aphasia quotients obtained from the Western Aphasia Battery-Revised with QOL scores obtained from the Stroke and Aphasia Quality of Life Scale-39 and discusses how the results are incorporated into long-term communication programs at a community-based center that employs an LPAA.

Language as a Stressor in Aphasia

BACKGROUND: Persons with aphasia often report feeling anxious when using language while communicating. While many patients, caregivers, clinicians and researchers would agree that language may be a stressor for persons with aphasia, systematic empirical studies of stress and/or anxiety in aphasia remain scarce. AIM: The aim of this paper is to review the existing literature discussing language as a stressor in aphasia, identify key issues, highlight important gaps, and propose a program for future study. In doing so, we hope to underscore the importance of understanding aspects of the emotional aftermath of aphasia, which plays a critical role in the process of recovery and rehabilitation. MAIN CONTRIBUTION: Post stroke emotional dysregulation in persons with chronic aphasia clearly has adverse effects for language performance and prospects of recovery. However, the specific role anxiety might play in aphasia has yet to be determined. As a starting point, we propose to view language in aphasia as a stressor, linked to an emotional state we term "linguistic anxiety." Specifically, a person with linguistic anxiety is one in whom the deliberate, effortful production of language involves anticipation of an error, with the imminence of linguistic failure serving as the threat. Since anticipation is psychologically linked to anxiety and also plays an important role in the allostatic system, we suggest that examining physiologic stress responses in persons with aphasia when they are asked to perform a linguistic task would be a productive tool for assessing the potential relation of stress to "linguistic anxiety." CONCLUSION: Exploring the putative relationship between anxiety and language in aphasia, through the study of physiologic stress responses, could establish a platform for investigating language changes in the brain in other clinical populations, such as in individuals with Alzheimer's disease or persons with post traumatic stress disorder, or even with healthy aging persons, in whom "linguistic anxiety" might be at work when they have trouble finding words.