Communication partner training in traumatic brain injury: a UK survey of Speech and Language Therapists' clinical practice

A Scoping Review of Implementation Science Studies in the Field of Traumatic Brain Injury: State of the Science and Future Directions

OBJECTIVE

Implementation research is essential to accelerating the public health benefits of innovations in health settings. However, the US National Academies of Sciences, Engineering, and Medicine 2022 report identified a lag in published implementation research applied to traumatic brain injury (TBI). Our objectives were to characterize implementation science studies published to date in TBI clinical care and rehabilitation and provide recommendations for future directions.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Articles published between 2011 and 2023 were identified (MEDLINE, PubMed, PsychInfo, and Web of Science), and included if the study focused on the TBI population, measured at least one Proctor (2011) implementation outcome and aligned with implementation research designs. Data were charted using an extraction template.

RESULTS

Of the 38 articles, 76% were published between 2018 and 2023. About 37% of articles were in the pre-implementation phase, and 57.9% were in the implementation phase. Over half of articles used a theory, model, or framework to guide the research. Fifteen studies were descriptive, 10 were qualitative, 7 were mixed methods, and 4 were randomized controlled trials. Most studies investigated implementation outcomes regarding national guidelines following TBI or TBI symptom management. Adoption (42.1%) and fidelity (42.1%) were the most commonly studied implementation outcomes, followed by feasibility (18.4%), acceptability (13.2%), and penetration (10.5%). Only 55% of studies used or tested the effectiveness of one or more implementation strategies, with training and education used most commonly, followed by data warehousing techniques.

CONCLUSIONS

Future research should prioritize the selection and investigation of implementation strategy effectiveness and mechanisms across contexts of care and use implementation research reporting standards to improve study rigor. Additionally, collaborative efforts between researchers, community partners, individuals with TBI, and their care partners could improve the equitable translation of innovations across service contexts.

An exploration of UK speech and language therapists' treatment and management of functional communication disorders: A mixed-methods online survey

BACKGROUND

Functional Communication Disorders (FCDs) are one specific presentation of Functional Neurological Disorder (FND). FND is characterised by neurological symptoms, such as sensory and motor symptoms, which are not explained by neurological disease. Speech and language therapists (SLTs) have expertise in managing communication disorders, including FCDs, though is not known is what clinicians do in practice to treat and manage FCDs.

AIM

To explore the clinical practices of SLTs who regularly manage FCDs in the UK, including the assessment and intervention approaches taken.

METHODS & PROCEDURES

An online survey was developed using Qualtrics software and piloted before dissemination. Participants were experienced SLTs working in the UK who managed at least three FCD referrals a year. The survey was developed with a mix of qualitative and quantitative questions. The survey was disseminated via social media and professional networks.

OUTCOMES & RESULTS

There were 73 completed responses to the survey. Participants reported working with a range of FCDs clinically, with functional stuttering and articulation disorders seen most frequently. SLTs reported working with a wide range of multidisciplinary professionals when managing patients with FCDs, though lack of access to mental health professionals was raised as an issue. SLTs reported using a combination of formal and informal communication assessments. Interventions varied, with a wide range of psychological approaches informing treatment. Lack of specific training, evidence base and negative attitudes around functional neurological disorder (FND) were raised as ongoing issues.

CONCLUSIONS & IMPLICATIONS

Therapists encountered a wide range of FCDs as part of their clinical practice, though there was a significant disparity in the service and interventions offered. SLTs feel their input can be effective, but lack the resources, training and evidence-based interventions to provide adequate care.

WHAT THIS PAPER ADDS

What is already known on the subject FCDs are one manifestation of FND and can present as a wide range of communication disorders. SLTs encounter FCDs as part of clinical practice, but report feeling unsure and underprepared to manage these disorders. Consensus recommendations have provided some guidance on how to manage these disorders, though what was not known was what practising SLTs are doing in practice with FCD patients: what assessment, intervention and management strategies they use, and what they feel are the facilitators and barriers to effective management. What this study adds to the existing knowledge This is the first UK-wide survey of FCD SLT clinical practice. The survey found that SLTs are seeing a range of FCDs as part of their clinical practice. SLTs reported that they feel their input is effective, that they had confidence in their ability to provide assessment and intervention, and that SLT for FCDs should be routine. SLTs reported using a wide variety of approaches to assessment and intervention. Barriers to effective management included a lack of resources, training, negative staff attitudes towards FND, and lack of research and evidence-based interventions. What are the practical and clinical implications of this work? This survey has found that SLTs working across the UK are providing input for patients with FCDs, but frequently reported feeling isolated and lacking clinical peer support. This shows the potential for networking groups to support SLTs to learn and share resources. There is a training need for SLTs and other healthcare professionals to tackle pervasive negative attitudes towards FND. Common themes in intervention approaches were found, but there was variability in the specific approach taken. This requires further research to guide SLTs on the best evidence-based practice.

Digital, co-created implementation of communication partner training programs for stroke, brain injury, and dementia: Past, present, and future

PURPOSE

Communication partner training is a recommended intervention for partners of people with acquired brain injury. In this paper we explore the past, present, and future of communication partner training (CPT) based on our 2023 Speech Pathology Australia national conference address.

METHOD

We focus on our research team's contributions, and highlight research knowledge across stroke, traumatic brain injury (TBI), and dementia. This work is anchored in the voice of people with communication disability. One partner in the CPT journey, Rosey Morrow, co-authors this paper.

RESULT

The CPT evidence base for acquired neurological conditions is growing, including in the areas of technology, co-design, and translation. However, knowledge and implementation gaps remain.

CONCLUSION

The future of CPT will require us to harness co-design and technology, whilst meeting the implementation challenges of complex systems to enable communication for all.

Communication partner training for student health and social care professionals engaging with people with stroke acquired communication difficulties: A protocol for a realist review

Background

Stroke acquired communication impairments impede effective communication. Consequently, in stroke care, communicative interactions can be challenging for both patients and staff and can predispose patients to increased risk of preventable adverse events. Communication partner training (CPT) can mitigate such negative outcomes by optimising communicative interactions. Providing CPT to student health and social care professionals (SH&SCPs) has the potential to enhance their clinical expertise and experiences and enhance the future clinical care of patients with stroke acquired communication impairments. This research aims to expand our understanding of how CPT is operationalised for SH&SCPs in higher education institutions and determine: what works; for whom; in what contexts; how and why?

Methods

This review is Phase 1 of a research project employing a realist approach with public and patient involvement (PPI). It incorporates five iterative steps: 1.) Clarifying the scope; 2.) Searching for evidence; 3.) Selecting and appraising evidence; 4.) Data extraction; 5.) Synthesising data and developing a middle range theory explaining how CPT is expected to work for SH&SCPs. An advisory panel, including PPI advisors, content advisors, student advisors, realist advisors and educationalist advisor has been set up to consult throughout the review and collaboratively agree the middle range theory.

Discussion

While there is an evolving evidence base for CPT, including stroke specific CPT for SH&SCPs, it is acknowledged that there are challenges to its implementation in complex real-world settings. In combining empirical evidence with theoretical understanding, realist review permits synthesis of data from diverse sources and goes beyond determining efficacy to explore generative causation and solutions for real world practice. A middle range realist programme theory that coherently explains how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments will provide educators with new insights into CPT development and implementation in their higher education institutions.

A qualitative exploration of speech-language pathologists' approaches in treating spoken discourse post-traumatic brain injury

BACKGROUND

Spoken discourse impairments post-traumatic brain injury (TBI) are well-documented and heterogeneous in nature. These impairments have chronic implications for adults in terms of employment, socializing and community involvement. Intervention delivered by a speech-language pathologist (SLP) is recommended for adults with discourse impairments post-TBI, with an emphasis on context-sensitive treatment. The developing evidence base indicates a wide array of treatment components for SLPs to evaluate and implement within their clinical practice. However, there is limited insight into how SLPs are currently treating discourse impairments and the rationales informing clinical practice.

AIMS

To explore the under-researched area of clinical practice for spoken discourse interventions with adults post-TBI, including treatment components and clinician rationales, and to contribute towards a shared knowledge base.

METHODS & PROCEDURES

Participants were recruited via purposeful sampling strategies. Six SLPs participated from Australia, the United Kingdom (UK) and the United States (US). Semi-structured interviews were conducted via Zoom. Interviews were manually transcribed, coded and analysed via a qualitative content analysis approach.

OUTCOMES & RESULTS

Participants described discourse treatment practices across various settings and TBI recovery stages. Results indicated that SLPs used numerous treatment activities, resources and outcome measures. Intervention approaches primarily targeted social communication skills, strategy development/utilization and insight-building. Clinical practice conformed to available guidelines where possible, reflected best practice and incorporated components of the research literature. Participants reported using individualized treatment activities aimed at addressing client-specific factors and rationales prioritized tailored, context-sensitive and goal-directed treatment.

CONCLUSIONS & IMPLICATIONS

This study provided insight into a previously under-researched area. It highlighted a wide range of treatment activities and factors informing current SLPs' treatment of spoken discourse impairment post-TBI. Overall, clinical practice and rationales discussed in this study were aligned with best practice and emphasized a contextualized, individualized approach to discourse treatment across service settings and stages of recovery. Participants identified areas requiring further support, including access to training, resources and research, and the challenge of finding suitable outcome measures. Further investigation into discourse management post-TBI, from initial assessment to outcome measurement, may help inform clinical decision-making and the transfer of research to practice.

WHAT THIS PAPER ADDS

What is already known on the subject Spoken discourse impairments occur in dialogic and monologic productions post-TBI. Interventions targeting both genres are detailed within the research literature; however, studies exploring clinical practice and decision-making for discourse interventions post-TBI are limited. What this paper adds to existing knowledge This study provides new insight into the current treatment targets, activities, resources and outcome measures employed by clinicians supporting adults with discourse impairment post-TBI. It details the factors that influence clinical decision-making for this caseload and identifies an emphasis on client priorities and the value of clinician experience. What are the potential or actual clinical implications of this work? This study identifies the broad and complex considerations required to deliver context-sensitive discourse intervention post-TBI. It indicates the need for an in-depth review from assessment to treatment outcomes to better understand and support this area of practice and to direct future research. This study also highlighted the role of clinician experience in discourse intervention and the value of sharing clinical knowledge and resources within and across the profession to support all levels of clinician experience.

Co-constructed communication therapy for individuals with acquired brain injury: A systematic review

BACKGROUND

Meaningful, varied, joyful conversation is an important therapy target for adults with language or cognitive-communication disorders following acquired brain injury (ABI). However, the complexity of daily communication is often reduced to component parts within intervention programmes, with mixed evidence of generalization to everyday conversation. Interventions targeting co-construction of communication within a dyad offer a structured way in which to retain and treat elements of everyday conversation for individuals and their communication partner (CP). Such interventions exist but they are variably labelled, target different ABI populations and have not been synthesized.

AIMS

To identify the nature, scope and effects of intervention studies targeting co-constructed communication in adults with ABI.

METHOD

This systematic review was completed using PRISMA Guidelines. Six databases (MEDLINE, Embase, CINAHL, Scopus, LLBA, PsychInfo) were searched and 1210 studies were screened. Data were extracted and studies were rated for methodological quality and completeness of reporting. Outcome measures and effects of treatment were collated through descriptive synthesis.

MAIN CONTRIBUTION

This review highlights an emerging evidence base in relation to an intervention approach that targets everyday communication. Co-constructed communication interventions have been reported by 13 studies, from a total of 206 participants with post-stroke aphasia, traumatic brain injury and progressive language impairments. These interventions take a range of formats, including referential communication tasks, retell/recount therapies and communication training programmes. Methodological quality evaluation indicated mostly low-level study designs. Heterogeneity was identified in primary outcome measures, with 28 unique primary outcome measures reported across studies. Most studies demonstrated change in task-specific or broad communication outcome measures.

CONCLUSIONS

Co-constructed communication interventions may offer clinicians a systematic, protocolized, replicable way to target everyday communication for adults with ABI. More high-quality, experimental designs with complete reporting and psychometrically sound outcome measures are needed to strengthen the evidence base.

WHAT THIS PAPER ADDS

What is already known on this subject Everyday conversation is an important therapy target for adults with ABI, but there is mixed evidence of therapy gains generalizing to everyday life. Many interventions reduce conversation to component parts such as naming or sentence construction. A different approach is needed to capture the social, dyadic, interactive and multifaceted nature of conversation. We propose the term 'co-constructed communication interventions' as a therapy genre targeting semi-structured dialogue. These interventions retain elements of everyday conversation (such as multimodal communication and situating tasks within dyads), combined with experimental elements (where stimuli prompt interactions and responses can be scored against normative data). What this paper adds to existing knowledge This review proposes and describes a distinct genre of discourse intervention within the current evidence base with a novel operational definition of 'co-constructed communication'. What are the potential or actual clinical implications of this work? Co-constructed communication interventions directly target elements of everyday communication by situating the therapy goals within a dyadic, interactive, multimodal task. A range of intervention tasks have been identified, including collaborative storytelling and problem-solving. This review will be of interest to clinicians working with adults with ABI; co-constructed communication interventions may offer a useful, replicable way to target aspects of everyday communication. This synthesis of the current evidence base encourages clinicians' informed, evidence-based decisions around these interventions.

Cognitive-communication difficulties due to traumatic brain injury sustained in adults 55 years and older: A survey of speech-language pathology professional practice in Australia

PURPOSE

Limited research informs management of cognitive-communication difficulties following traumatic brain injury (TBI) in older adulthood. The purpose of this study was to understand the characteristics and practice of speech-language pathologists (SLPs) working with people who sustained TBI at ≥55 years and more specifically their management of cognitive-communication difficulties with this population. This included assessment and treatment practices, resource needs, barriers to practice, and impact to service delivery from COVID-19 restrictions.

METHOD

A cross-sectional survey-based design with non-probability sampling of SLPs working in Australia with adults with TBI was utilised. Descriptive statistics and content analysis were used for analysis of survey data.

RESULT

Fifty responses were eligible for inclusion. Participants predominantly worked in inpatient rehabilitation (48%), acute (40%), and community settings (36%). Service delivery to adults who sustained TBI at ≥55 years commonly included cognitive-communication management. Assessment and treatment trends are described. Most SLPs (74%) perceived barriers to cognitive-communication management, often relating to time and funding, that existed prior to the COVID-19 pandemic. Pandemic restrictions presented additional challenges.

CONCLUSION

Research relating to cognitive-communication difficulties following TBI in older adulthood is required to support evidence-based practice and inform services for older adults who sustain TBI.

Digital Health Implementation Strategies Coproduced With Adults With Acquired Brain Injury, Their Close Others, and Clinicians: Mixed Methods Study With Collaborative Autoethnography and Network Analysis

BACKGROUND

Acquired brain injuries (ABIs), such as stroke and traumatic brain injury, commonly cause cognitive-communication disorders, in which underlying cognitive difficulties also impair communication. As communication is an exchange with others, close others such as family and friends also experience the impact of cognitive-communication impairment. It is therefore an internationally recommended best practice for speech-language pathologists to provide communication support to both people with ABI and the people who communicate with them. Current research also identifies a need for neurorehabilitation professionals to support digital communication, such as social media use, after ABI. However, with >135 million people worldwide affected by ABI, alternate and supplementary service delivery models are needed to meet these communication needs. The "Social Brain Toolkit" is a novel suite of 3 interventions to deliver communication rehabilitation via the internet. However, digital health implementation is complex, and minimal guidance exists for ABI.

OBJECTIVE

This study aimed to support the implementation of the Social Brain Toolkit by coproducing implementation knowledge with people with ABI, people who communicate with people with ABI, clinicians, and leaders in digital health implementation.

METHODS

A maximum variation sample (N=35) of individuals with living experience of ABI, close others, clinicians, and digital health implementation leaders participated in an explanatory sequential mixed methods design. Stakeholders quantitatively prioritized 4 of the 7 theoretical domains of the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as being the most important for Social Brain Toolkit implementation. Qualitative interview and focus group data collection focused on these 4 domains. Data were deductively analyzed against the NASSS framework with stakeholder coauthors to determine implementation considerations and strategies. A collaborative autoethnography of the research was conducted. Interrelationships between considerations and strategies were identified through a post hoc network analysis.

RESULTS

Across the 4 prioritized domains of "condition," "technology," "value proposition," and "adopters," 48 digital health implementation considerations and 52 tailored developer and clinician implementation strategies were generated. Benefits and challenges of coproduction were identified. The post hoc network analysis revealed 172 unique relationships between the identified implementation considerations and strategies, with user and persona testing and responsive design identified as the potentially most impactful strategies.

CONCLUSIONS

People with ABI, close others, clinicians, and digital health leaders coproduced new knowledge of digital health implementation considerations for adults with ABI and the people who communicate with them, as well as tailored implementation strategies. Complexity-informed network analyses offered a data-driven method to identify the 2 most potentially impactful strategies. Although the study was limited by a focus on 4 NASSS domains and the underrepresentation of certain demographics, the wealth of actionable implementation knowledge produced supports future coproduction of implementation research with mutually beneficial outcomes for stakeholders and researchers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/35080.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs

BACKGROUND

After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context.

AIMS

(1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy.

METHODS & PROCEDURES

A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis.

OUTCOMES & RESULTS

The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general.

CONCLUSIONS & IMPLICATIONS

The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require.

WHAT THIS PAPER ADDS

What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

A Communication Partner Training Program Delivered via Telehealth for People Living With Parkinson's (Better Conversations With Parkinson's): Protocol for a Feasibility Study

BACKGROUND

Parkinson's can impact people's speech, cognition, pragmatics, and language, significantly affecting their conversations with others. The speech and language therapy approach called communication partner training (CPT) is effective for a range of communication difficulties. However, speech and language therapy interventions for people with Parkinson's predominantly focus on impairments, with little provision of CPT for this population. Better Conversations is a CPT approach that involves working with a dyad (the person with the communication difficulty and a conversation partner [CP]) to build conversation skills. It is effective at reducing barriers to conversation, and for some, it significantly increases targeted facilitatory strategies. Some approaches to CPT have been adapted to be delivered via telehealth. This can maximize ecological validity and convenience. Furthermore, telehealth is widely accepted as a delivery method for other interventions for Parkinson's. This study presents the protocol for a pilot feasibility study of a Better Conversations CPT delivered via telehealth to people living with Parkinson's and their CPs, called Better Conversations with Parkinson's (BCP).

OBJECTIVE

The primary aim is to evaluate the feasibility of the BCP program delivered via telehealth with a treatment group from a collaborating National Health Service (NHS) site to establish for a main trial whether BCP can be delivered as intended in an NHS setting. The aim is to establish: (1) the acceptability of the program for people living with Parkinson's, family members, and speech and language therapists (SLTs); (2) the feasibility of delivering the BCP program; (3) the recruitment and retention rates; (4) a sample size calculation; and (5) the most appropriate primary outcome measure.

METHODS

Ethical approval for this study was obtained from London-Central Research Ethics Committee (reference: 22/LO/0332). This case-series feasibility pilot study will recruit 10-12 dyads to ensure 10 complete data sets. Participants will be recruited by a collaborating NHS site located in England. Participants will be involved for 16 weeks (weeks 1-2 preintervention measures, weeks 3-8 intervention, weeks 10-12 postintervention measures, week 16 follow-up interview). Quantitative and qualitative methods will be used to analyze the study data. Speech, communication, and quality of life assessment data will be analyzed statistically to determine a suitably sensitive outcome measure. Descriptive statistics will be used to report on recruitment, attendance, and attrition. Finally, acceptability and feasibility will be evaluated using participant feedback, interviews, and the reflective diary and feedback of the SLT administering the therapy (by the research assistant who is the first author). This data will be analyzed using descriptive statistics and reflexive thematic analysis.

RESULTS

This study was approved for funding from Parkinson's UK. Study recruitment commenced in July 2022. The results of the data analysis are expected to be available by September 2024.

CONCLUSIONS

Insights from this study will provide valuable information about the acceptability and feasibility of a remotely delivered Better Conversations CPT approach for people living with Parkinson's and their CPs. An outcome of this study will be a manualized BCP program coproduced by people living with Parkinson's, their families, and a group of expert SLTs. The study results will guide the next stages of intervention development.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41416.

Community-based rehabilitation for adults with cognitive-communication disorders following traumatic brain injury: A mixed methods investigation

OBJECTIVE

To investigate the experiences and perspectives of speech pathologists when delivering cognitive-communication therapy to adults following traumatic brain injury (TBI).

METHODS

An explanatory sequential mixed methods design was used to explore the practices of speech pathologists working in community-based rehabilitation (CBR) settings. The first participant group completed an in-depth online survey, whilst the second group participated in an interview to discuss their processes and recommendations when managing adults following TBI.

RESULTS

Participants highlighted the need for services to be client-centered and inclusive in their approaches to meet the rehabilitation needs of people following TBI in community-based settings. The key features identified to achieve this included utilizing a flexible service delivery approach, implementation of meaningful therapy, as well as inclusion of significant others.

CONCLUSIONS

These findings provide a snapshot of the current practices employed by a range of speech pathology services across Australia and New Zealand. Health professionals and rehabilitation service providers should consider the key factors highlighted by the participants when designing future CBR models of care for this client group.