Aphasia rehabilitation in Australia: Current practices, challenges and future directions

Qualitative Exploration of Speech Pathologists' Experiences and Priorities for Aphasia Service Design: Initial Stage of an Experience-Based Co-Design Project to Improve Aphasia Services

INTRODUCTION AND AIMS

Stroke survivors with aphasia (impaired language/communication) have poor outcomes and gaps in the clinical implementation of best practice contribute to this. Little is known, however, about speech pathologist perspectives on the touchpoints (key moments shaping experiences) in the clinical care pathway that have the greatest impact on service delivery nor how this varies by geographical location. We explored the experiences of speech pathologists who provide aphasia services to establish priorities for improvement and design.

METHODS AND ANALYSIS

This is the initial experience gathering and priority identification stage of an experience-based co-design (EBCD) project. Speech pathologists were recruited from 21 geographically diverse Hospital and Health Services in Queensland, Australia. Speech pathologists working in acute, rehabilitation and community services shared positive and negative experiences of delivering aphasia care in interviews and focus groups. Experiential data were analysed using qualitative thematic analysis to determine touchpoints. Priorities for service design were identified using an adapted nominal group technique.

RESULTS

Speech pathologists (n = 62) participated in 16 focus groups and nine interviews and shared 132 experiences of delivering aphasia care. Providing care in teams with poor awareness of the impacts of aphasia was identified as a key challenge, as poor patient-provider communication was perceived to increase risk of adverse outcomes for patients. Speech pathologists identified areas for improvement related to their own professional needs (e.g., greater access to clinical supervision); collaborative health care (e.g., better coordination and interdisciplinary care to increase therapy time); and the service context and environment (e.g., psychological services able to support diverse communication needs).

CONCLUSIONS

Speech pathologist delivery of aphasia services could be improved through increased access to clinical supervision, opportunities for peer debriefing and interdisciplinary care. Priorities for service design varied by geographical location and included: education to support care transitions (remote areas), improved referral pathways and service linkage (regional areas) and dedicated aphasia staffing (metropolitan areas).

PATIENT OR PUBLIC CONTRIBUTION

A consumer advisory committee comprising people with aphasia (n = 3, authors K.M., K.D. and B.A.), their significant others (n = 2, authors J.D. and P.M.), and a Cultural Capability Officer (author G.B.) guided this research. The team: (1) reviewed participant information; (2) co-designed surveys and workshop resources; (3) copresented research outcomes and contributed to publications. Research questions and study design (e.g., analysis methods and assessment measures) were developed by the research team (authors L.A., V.J.P., D.A.C. and S.J.W.).

Experiences of People with Aphasia Receiving Enhanced Community-Based Speech-Language Pathology Provided by Speech-Language Pathology Students

INTRODUCTION

Treatment intensity for people with aphasia (PWA) is a significant factor in enhancing recovery. Personal factors such as fatigue, physical endurance, and motivation as well as clinician availability have been described as barriers to increased intensity. The use of student therapists has been shown to assist with addressing service gaps.

METHODS

The aim of the study was to explore the experiences of PWA who received enhanced community-based treatment delivered by speech-language pathology (SLP) students. Enhanced community-based treatment was defined as three or more treatment sessions per week targeting communication. Semi-structured interviews were conducted with 10 PWA living in New Zealand. Interview data were analysed with reflexive thematic analysis.

RESULTS

Two themes and six sub-themes were developed. Theme 1 related to intensity and included more treatment is better than less (sub-theme 1), there's a "right time" for more intensive treatment (sub-theme 2), the hard work is worth the effort (sub-theme 3). Theme 2 related to working with SLP students; it didn't feel like they were students (sub-theme 4), we just got on so well (sub-theme 5), and they listened to what I wanted (sub-theme 6).

CONCLUSIONS

The findings confirm that PWA value access to more intensive treatment and desire involvement in decisions about flexible treatment schedules. PWA have positive experiences when treatment is provided by SLP students. Implications for clinical practice and future research directions are discussed.

From concept to practice: a scoping review of the application of AI to aphasia diagnosis and management

PURPOSE

Aphasia is an acquired communication disability resulting from impairments in language processing following brain injury, most commonly stroke. People with aphasia experience difficulties in all modalities of language that impact their quality of life. Therefore, researchers have investigated the use of Artificial Intelligence (AI) to deliver innovative solutions in Aphasia management and rehabilitation.

MATERIALS AND METHODS

We conducted a scoping review of the use of AI in aphasia research and rehabilitation to explore the evolution of AI applications to aphasia, the progression of technologies and applications. Furthermore, we aimed to identify gaps in the use of AI in Aphasia to highlight the potential areas where AI might add value. We analysed 77 studies to determine the research objectives, the history of AI techniques in Aphasia and their progression over time.

RESULTS

Most of the studies focus on automated assessment using AI, with recent studies focusing on AI for therapy and personalised assistive systems. Starting from prototypes and simulations, the use of AI has progressed to include supervised machine learning, unsupervised machine learning, natural language processing, fuzzy rules, and genetic programming.

CONCLUSION

Considerable scope remains to align AI technology with aphasia rehabilitation to empower patient-centred, customised rehabilitation and enhanced self-management.

Comprehensive quality assessment for aphasia rehabilitation after stroke: protocol for a multicentre, mixed-methods study

INTRODUCTION

People with aphasia following stroke experience disproportionally poor outcomes, yet there is no comprehensive approach to measuring the quality of aphasia services. The Meaningful Evaluation of Aphasia SeRvicES (MEASuRES) minimum dataset was developed in partnership with people with lived experience of aphasia, clinicians and researchers to address this gap. It comprises sociodemographic characteristics, quality indicators, treatment descriptors and outcome measurement instruments. We present a protocol to pilot the MEASuRES minimum dataset in clinical practice, describe the factors that hinder or support implementation and determine meaningful thresholds of clinical change for core outcome measurement instruments.

METHODS AND ANALYSIS

This research aims to deliver a comprehensive quality assessment toolkit for poststroke aphasia services in four studies. A multicentre pilot study (study 1) will test the administration of the MEASuRES minimum dataset within five Australian health services. An embedded mixed-methods process evaluation (study 2) will evaluate the performance of the minimum dataset and explore its clinical applicability. A consensus study (study 3) will establish consumer-informed thresholds of meaningful change on core aphasia outcome constructs, which will then be used to establish minimal important change values for corresponding core outcome measurement instruments (study 4).

ETHICS AND DISSEMINATION

Studies 1 and 2 have been registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12623001313628). Ethics approval has been obtained from the Royal Brisbane and Women's Hospital (HREC/2023/MNHB/95293) and The University of Queensland (2022/HE001946 and 2023/HE001175). Study findings will be disseminated through peer-reviewed publications, conference presentations and engagement with relevant stakeholders including healthcare providers, policy-makers, stroke and rehabilitation audit and clinical quality registry custodians, consumer support organisations, and individuals with aphasia and their families.

The Communicative Participation Item Bank-Gender-Diverse Version: Item Bank Calibration and Short Form

PURPOSE

The purpose of this study was to calibrate an item set for a new version of the Communicative Participation Item Bank (CPIB) specifically for use with gender-diverse clients. This new version contains a new item stem as well as other minor wording changes from the original CPIB in order to be acceptable to gender-diverse respondents.

METHOD

Survey data on 47 candidate items were collected from 434 transgender individuals: 219 assigned female at birth (AFAB) and 215 assigned male at birth (AMAB). Item response theory analyses included evaluation of unidimensionality, local dependence, fit to a graded response model, and differential item functioning (DIF) between AFAB and AMAB respondents.

RESULTS

The original set of 47 items was unidimensional, but 16 items were removed due to local dependence, resulting in a final item bank of 31 items. There was no evidence of DIF between AFAB and AMAB participants. Reliability of the full item bank is good (i.e., > 0.8) between T scores of 20 and 76 and high (i.e., > 0.9) between T scores of 20 and 68. The short form had good reliability (i.e., > 0.8) between T scores of 24 and 64.

CONCLUSIONS

The Communicative Participation Item Bank-Gender-Diverse (CPIB-GD) version provides a new option for person-reported outcome measurement with gender-diverse clients. Clinicians are cautioned to use only the new CPIB-GD with gender-diverse clients, and not the original CPIB due to unacceptable wording in the original version for this population. The original CPIB remains valid and appropriate for the populations for which it was developed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24993309.

How do speech and language therapists enact aphasia psychosocial support in Ireland? A cross-sectional online survey informed by normalization process theory

BACKGROUND

Supporting psychosocial well-being in aphasia is necessarily person-centred, interdisciplinary and coordinated. Shortcomings in such support are described in Ireland and elsewhere. Speech and language therapists (SLTs) are integral; and describing current practice and barriers they experience is important for enhancing service delivery.

AIMS

To understand how SLTs enact, and are supported to enact, aphasia psychosocial care in Ireland.

METHODS & PROCEDURES

This is a cross-sectional, online, self-administered clinician survey targeting SLTs working minimally 1 year post-qualification with persons with aphasia of any aetiology in Ireland. The survey questions were charted against key constructs of the implementation science framework, normalization process theory (NPT), and descriptive statistics were applied.

OUTCOMES & RESULTS

A total of 54 eligible datasets were included. SLTs believed psychosocial support to be part of their role, but perceived multiple barriers in enacting it. These included a lack of training, clinical supervision, management support, role recognition, and access to and joint working with mental health professionals and services.

CONCLUSIONS & IMPLICATIONS

SLTs in Ireland face a range of individual and structural barriers, including care coordination and resourcing. There is a clear need not only for training, upskilling and mentorship, but also for wider changes around access to mental health professionals and clarity around the processes of referral, coordination and integration of aphasia care across settings. These findings comprise preliminary insights into current practices. Further research is needed as well as clarity on best-practice pathways for different aetiologies of aphasia. Articulating current practices using NPT may have utility for developing empirically informed and principled interventions to improve service delivery.

WHAT THIS PAPER ADDS

What is already known on this subject People with aphasia of all aetiologies are at risk of psychosocial problems. Shortcomings in access and the availability of appropriate support have been documented both internationally and in Ireland. To address this issue, an important first step is to understand how SLTs in Ireland currently enact and are supported to enact aphasia psychosocial care. What this study adds to the existing knowledge The findings describe the potential levers and barriers to progressing aphasia psychosocial care in Ireland. A range of individual, team and structural factors were identified. These were locally contextualized but similar issues are reported in other countries. Linking attitudes with NPT constructs provides a first step for further principled implementation projects. What are the practical and clinical implications of this study? Addressing psychosocial problems is perceived as a legitimate part of the speech and language therapy role. SLTs in Ireland enact a range of therapeutic approaches but may need opportunities for formal training and supervision, and for better coordination and integration with other mental health services and disciplines. Understanding differences in care pathways across the range of aphasia aetiologies is additionally important given the emphasis on post-stroke aphasia in the literature.

Developing consensus-based clinical competencies to guide stroke clinicians in the implementation of psychological care in aphasia rehabilitation

Background People with aphasia experience depression and anxiety associated with negative outcomes across a range of time post-stroke. Stroke clinicians are well-positioned to facilitate low-intensity psychotherapeutic interventions after aphasia (e.g. mood screening, behavioural activation, problem-solving therapy, relaxation therapy); however, they self-report a lack of knowledge, skills and confidence to do so. The Theoretical Domains Framework (TDF) provides a lens through which to view and target clinician behaviours and training needs in this area of practice. The aim of this study was to develop and gain consensus on items for a rating scale of clinical competencies in facilitating individual-based, low-intensity psychotherapeutic interventions for people with aphasia. Methods An e-Delphi methodology using focus groups and survey rounds was used to gain consensus on clinical competencies considered important. Results Eight stroke clinicians (speech pathologists and psychologists), two people with aphasia and three family members participated in one of four focus groups. Four themes were derived from the data: (1) Communication support, (2) Assessment and therapy structure, (3) Interpersonal skills, and (4) Needs of the significant other (family or friend). Themes informed an initial list of 23 self-rated and observer-rated competency items. Following two rounds of e-Delphi surveys, 11 stroke clinicians (six speech pathologists and five psychologists) reached consensus (80-100%) for 19 competencies. Conclusions The Psychological Care in Aphasia Rehabilitation Competency scale offers a preliminary list of items to guide and train clinicians to implement low-intensity psychotherapeutic interventions for people with aphasia.

"There are endless areas that they can use it for": speech-language pathologist perspectives of technology support for aphasia self-management

BACKGROUND

Aphasia is a debilitating acquired language disorder that often persists as a chronic condition. However, long-term support options are scarce, necessitating the consideration of alternative approaches. Chronic condition self-management approaches, which aim to build self-efficacy and empower people to take responsibility for the day-to-day management of their health condition, may benefit people with aphasia (PwA). Technology is widely used in chronic condition self-management and investigation is required to determine whether it could play a role in aphasia self-management.

OBJECTIVE

This study aimed to explore speech-language pathologist (SLP) perspectives on the potential use of technology to support aphasia self-management.

METHODS

A qualitative study was conducted with 15 SLPs using semi-structured interviews. Qualitative content analysis was applied to verbatim transcripts to identify codes, categories, and sub-themes which were developed into themes.

RESULTS

Three themes were identified: (1) technology supports holistic aphasia self-management by providing additional avenues for service delivery, overall communication, and learning opportunities thus enhancing independence and life participation; (2) SLP and communication partner (CP) assistance can support PwA to use technology for aphasia self-management; (3) considerations and potential barriers to PwA use of technology for aphasia self-management.

CONCLUSIONS

Technology can support aphasia self-management by expanding service delivery options, allowing for increased frequency and intensity of therapy practise, and facilitating communication and participation. Personal, professional, and organizational barriers should be addressed in the development of technology-enabled aphasia self-management approaches. SLPs and CPs can offer PwA assistance with technology but may themselves need additional support. Solutions for identified barriers should be considered, such as providing training in the use of technology and implementing aphasia-friendly modifications.IMPLICATIONS FOR REHABILITATIONSelf-management approaches are being explored in the area of aphasia management as a means of offering a holistic, sustainable intervention option that meets the long-term needs of people with aphasia.A range of technology-based resources are currently used in chronic condition self-management and in aphasia therapy, and there are many possibilities for the use of technology in aphasia self-management approaches.Speech-language pathologists identified that technology could facilitate aphasia self-management by expanding service delivery options (e.g., real-time and asynchronous telepractice), enabling increased frequency and intensity of therapy through providing a means of independent practise, offering options for augmentative alternative communication, and enhancing life participation by supporting social communication and daily tasks.,Speech-language pathologists are interested in using technology for aphasia self-management; however, barriers related to organizational policies, individual experience and confidence using technology, and technology itself must be addressed.

The role of education, concept knowledge, work setting and clinical experience in communication partner training: A survey of Flemish speech and language therapists

BACKGROUND

Aphasia can affect the communication between the person with aphasia (PWA) and the communication partner (CP). It is therefore necessary to support both the PWA and their CPs. Communication partner training (CPT) focuses on training communication between dyads of whom one person has aphasia. Although there is increasing evidence supporting CPT as an effective intervention to improve communication and reduce the psychosocial consequences of stroke, implementation in clinical practice remains limited.

AIM

To understand the mechanisms behind the practice-evidence gap currently hindering CPT implementation, this study investigated the role of (1) education, (2) concept knowledge, (3) work setting and (4) clinical experience in CPT.

METHODS & PROCEDURES

Flemish speech and language therapists (SLTs) clinically involved in aphasia rehabilitation were surveyed online regarding CPT. Statistical analyses include descriptive statistics to report survey results and non-parametric group comparisons to investigate the role of the four variables on CPT.

OUTCOMES & RESULTS

In this study 72 SLTs were included, of whom 73.61% indicated they deliver CPT but of whom only 43.10% indicated CP presence during therapy. The most frequently identified barriers to CPT delivery were lack of time and CPT-specific knowledge. Other barriers were lack of resources, work setting dependent factors, PWA or CP dependent factors, individual therapy to the PWA being of higher priority, existing CPT methods and interventions being perceived as unclear and feeling uncertain about CPT delivery. Concerning the role of the four variables on CPT delivery, neither education nor concept knowledge had a significant effect on CPT delivery. Work setting and clinical experience did, however, influence CPT delivery. More specifically, CPT delivery and CP presence were higher in the private practice (chronic phase) compared to the other three settings and experienced SLTs deliver CPT more often compared with less experienced SLTs.

CONCLUSIONS & IMPLICATIONS

To reduce the practice-evidence gap, we suggest prioritising the two most frequently identified barriers, that is, lack of time and CPT-specific knowledge. To overcome the time barrier in CPT, we propose implementing automated natural speech analysis to reduce the workload. To enhance CPT-specific knowledge, speech and language therapy curricula should provide more in-depth theory and hands-on practice for CPT. In addition, increased awareness about CPT-specific methods is needed to further support clinical practice.

WHAT THIS PAPER ADDS

What is already known on the subject Communication partner training (CPT) is an effective intervention to improve communication and reduce the psychosocial consequences of stroke. Despite this evidence base, a current practice-evidence gap exists. What this study adds This is the first study to characterise CPT delivery in a Flemish cohort of speech and language therapists (SLTs). In addition, on a more international perspective, few studies have investigated the role of education, concept knowledge, work setting and clinical experience in CPT. We found that neither education nor concept knowledge has a significant effect on CPT delivery. CPT delivery and communication partner presence are significantly higher in the private practice compared to the hospital, rehabilitation centre or nursing home settings. Experienced SLTs deliver CPT more often compared with less-experienced SLTs. The two most prominent reported barriers include lack of time and CPT-specific knowledge. What are the clinical implications of this work? This study suggests reducing the practice-evidence gap by alleviating the main barriers identified, that is, lack of time and CPT-specific knowledge. Time-barriers can be addressed by implementing automated natural speech analyses. We additionally advocate for more in-depth theory and hands-on practice for CPT in speech and language therapy curricula.

'It's been an extraordinary journey': Experience of engagement from the perspectives of people with post-stroke aphasia

BACKGROUND

Engagement is recognized as an important factor in aphasia treatment response and outcomes, yet gaps remain in our understanding of engagement and practices that promote engagement from the client perspective.

AIMS

The purpose of this phenomenological study was to explore how clients with aphasia experience engagement during their inpatient aphasia rehabilitation.

METHODS & PROCEDURES

An interpretative phenomenological analysis approach guided the study design and analysis. Data were collected through in-depth interviews with nine clients with aphasia, recruited through purposive sampling, during their inpatient rehabilitation admission. Analysis was completed using a variety of analytic techniques including coding, memoing, triangulation between coders and team discussion.

OUTCOMES & RESULTS

The analysis revealed that for clients with aphasia in the acute phrase of recovery, the rehabilitation process resembles travelling on a journey through a foreign land. Successful engagement in the journey was accomplished when one had a therapist who served as a trusted guide and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable.

CONCLUSIONS & IMPLICATIONS

Engagement is a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. Findings from this work have implications for measuring engagement, training student clinicians to be skilled facilitators in engaging their clients and implementing person-centred practices that promote engagement within clinical settings.

WHAT THIS PAPER ADDS

What is already known on the subject Engagement is recognized as an important factor in rehabilitation treatment response and outcomes. Prior literature suggests that the therapist plays a critical role in facilitating engagement within the client-provider relationship. Communication impairments associated with aphasia may negatively impact a client's ability to develop interpersonal connections and participate in the rehabilitation process. There is a dearth of research directly exploring the topic of engagement in aphasia rehabilitation, particularly from the perspective of clients with aphasia. Capturing the client perspective can provide novel insights regarding practices to foster and maintain engagement in aphasia rehabilitation. What this paper adds to existing knowledge This interpretative phenomenological study revealed that for individuals with aphasia in the acute phase of recovery, the rehabilitation process resembles travelling on a sudden and foreign journey. Successful engagement in the journey was accomplished when one had a therapist who served as a 'trusted guide' and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable. Through the client experience, engagement is seen as a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. What are the potential or actual clinical implications of this work? The current study highlights the complexity and nuance of engagement within the rehabilitation context, which has implications for measuring engagement, training student clinicians to be skilled in engaging their clients and implementing person-centred practices that promote engagement within clinical settings. It is necessary to recognize that client and provider interactions (and thus engagement) are embedded in and influenced by the broader healthcare system. With this in mind, a patient-centred approach to engagement in aphasia care delivery cannot be achieved through individual efforts only and may require prioritization and action at the systems level. Future work is needed to explore barriers and facilitators to enacting engagement practices, in order to develop and test strategies to support practice change.

Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom

BACKGROUND

Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented.

AIMS

This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored.

METHODS & PROCEDURES

An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis.

OUTCOMES & RESULTS

Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP.

CONCLUSIONS & IMPLICATIONS

This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion.

WHAT THIS PAPER ADDS

What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study

BACKGROUND

Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders.

OBJECTIVE

This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders.

METHODS

Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes.

RESULTS

The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology.

CONCLUSIONS

Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

Non-invasive brain stimulation in the treatment of post-stroke aphasia: a scoping review

PURPOSE

Aphasia is an acquired language impairment that commonly results from stroke. Non-invasive brain stimulation (NIBS) might accelerate aphasia recovery trajectories and has seen mounting popularity in recent aphasia rehabilitation research. The present review aimed to: (1) summarise all existing literature on NIBS as a post-stroke aphasia treatment; and (2) provide recommendations for future NIBS-aphasia research.

MATERIALS AND METHODS

Databases for published and grey literature were searched using scoping review methodology. 278 journal articles, conference abstracts/posters, and books, and 38 items of grey literature, were included for analysis.

RESULTS

Quantitative analysis revealed that ipsilesional anodal transcranial direct current stimulation and contralesional 1-Hz repetitive transcranial magnetic stimulation were the most widely used forms of NIBS, while qualitative analysis identified four key themes including: the roles of the hemispheres in aphasia recovery and their relationship with NIBS; heterogeneity of individuals but homogeneity of subpopulations; individualisation of stimulation parameters; and much remains under-explored in the NIBS-aphasia literature.

CONCLUSIONS

Taken together, these results highlighted systemic challenges across the field such as small sample sizes, inter-individual variability, lack of protocol optimisation/standardisation, and inadequate focus on aphasiology. Four key recommendations are outlined herein to guide future research and refine NIBS methods for post-stroke aphasia treatment.

Assistive Completion of Agrammatic Aphasic Sentences: Amalgamation of NLP and Neurolinguistics-based Synthetic Dataset

Damage to the inferior frontal gyrus (Broca's area) can cause agrammatic aphasia wherein patients, although able to comprehend, lack the ability to form complete sentences. This inability leads to communication gaps which cause difficulties in their daily lives. The usage of assistive devices can help in mitigating these issues and enable the patients to communicate effectively. However, due to lack of large scale studies of linguistic deficits in aphasia, research on such assistive technology is relatively limited. In this work, we present two contributions that aim to re-initiate research and development in this field. Firstly, we propose a model that uses linguistic features from small scale studies on aphasia patients and generates large scale datasets of synthetic aphasic utterances from grammatically correct datasets. We show that the mean length of utterance, the noun/verb ratio, and the simple/complex sentence ratio of our synthetic datasets correspond to the reported features of aphasic speech. Further, we demonstrate how the synthetic datasets may be utilized to develop assistive devices for aphasia patients. The pre-trained T5 transformer is fine-tuned using the generated dataset to suggest 5 corrected sentences given an aphasic utterance as input. We evaluate the efficacy of the T5 model using the BLEU and cosine semantic similarity scores. Affirming results with BLEU score of 0.827/1.00 and semantic similarity of 0.904/1.00 were obtained. These results provide a strong foundation for the concept that a synthetic dataset based on small scale studies on aphasia can be used to develop effective assistive technology.Clinical relevance- We demonstrate the utilization of Natural Language Processing (NLP) for developing assistive technology for Aphasia patients. While disorders like Broca's aphasia offer a small sample size of patients and data, synthetic linguistic models like ours offer extensive scope for developing assistive technology and rehabilitation monitoring.

Assessment and rehabilitation of acquired communication disorders in Aboriginal and Torres Strait Islander adults with stroke or traumatic brain injury: a retrospective chart review

PURPOSE

Speech-language pathologists' (SLP) management practices for Aboriginal and Torres Strait Islander adults with acquired communication disorder (ACD), following stroke or traumatic brain injury (TBI), are not well understood. This study explores SLPs' management approaches for ACDs for Aboriginal and Torres Strait Islander adults post-stroke or TBI.

MATERIALS AND METHODS

SLPs' documented notes were analysed from a two-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years), admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI.

RESULTS

SLPs frequently used informal approaches to assess ACDs. English-language formal assessment tools were also used in conjunction with the informal approaches. ACD diagnosis was more common in stroke than TBI patients. One-third of patients with ACD received inpatient rehabilitation at the study site. SLPs infrequently documented cultural or linguistic adaptions to assessment or interventions.

CONCLUSIONS

Informal approaches to assess ACDs were commonly employed which may be because they are perceived to be more culturally appropriate. Clinical guidelines for stroke and TBI should accommodate the diversity of cultures and languages. Better consideration of Aboriginal and Torres Strait Islander communication styles and incorporation of these into SLP ACD management approaches may facilitate accurate diagnosis and culturally safe rehabilitation services.Implications for RehabilitationInformal approaches for assessment and intervention of ACDs, that incorporate yarning and salient tasks, are likely to be more culturally appropriate and safe for Aboriginal and Torres Strait Islander peoples.More flexibility and guidance in the use of culturally and linguistically appropriate alternative assessment approaches are required in the National stroke guidelines for Aboriginal and Torres Strait Islander peoples.The adoption of enhanced models of culturally secure ACD service provision, that incorporate frequent SLP engagement with an Aboriginal or Torres Strait Islander support person during assessment and rehabilitation, are needed.There is an imperative for health professionals to actively account for culture and language difference in rehabilitation practices to ensure Indigenous peoples worldwide receive equitable and culturally-responsive services.

"Self-management has to be the way of the future": Exploring the perspectives of speech-language pathologists who work with people with aphasia

PURPOSE

Healthcare models have incorporated self-management approaches to facilitate increased patient responsibility for chronic condition management. As aphasia is a chronic condition, self-management may be beneficial for people with aphasia; however, the possible impacts of the language disorder on self-management must be acknowledged and addressed. Speech-language pathologists would likely be principal providers of self-management support; therefore, their perspectives should be sought when considering development of aphasia self-management approaches. This study aims to explore speech-language pathologist perspectives of aphasia self-management.

METHOD

In-depth, semi-structured interviews conducted with 15 speech-language pathologists in Australia. Interview data analysed using qualitative content analysis.

RESULT

Aphasia self-management was viewed as a person- and family-centred approach enabling comprehensive long-term care for people with aphasia and promoting control, responsibility, and independence. Speech-language pathologists were seen to have a substantial role providing self-management support and consultation, and training was required to expand this role. Communication partners and peer support were highly valued. Personal and environmental factors may influence successful aphasia self-management. Differences between aphasia self-management and chronic condition self-management were considered.

CONCLUSION

Self-management could facilitate long-term sustainable aphasia management. Aphasia self-management approaches should factor in how to maximise communication partner and peer support. Aphasia-friendly self-management resources are necessary.

The nature of inpatient rehabilitation for people with aphasia from culturally and linguistically diverse backgrounds: a scoping review

BACKGROUND

Due to language and cultural barriers, people with aphasia from culturally and linguistically diverse (CALD) backgrounds are at risk of disadvantage in their access to comprehensive care. They are at higher risk of poorer inpatient outcomes in addition to challenges in receiving appropriate aphasia assessment and intervention.

OBJECTIVES

This study aims to examine the extent and nature of what is known about the inpatient phase of aphasia rehabilitation for CALD stroke survivors and identify potential research gaps in the literature for investigation.

METHODS

A scoping review with systematic search was conducted in September 2020 following the PRISMA Scoping Review checklist. Five electronic databases were searched using a combination of terms pertaining to "aphasia," "inpatient care" and "CALD." Key variables were extracted from studies that met the inclusion criteria for analysis.

RESULTS

Eighteen studies were yielded. Data regarding the inpatient phase of care indicate that CALD people with aphasia do not always receive comprehensive assessment or intervention in all their languages that may impact their discharge destination and access to community services. Speech-language pathologists (SLPs) report numerous barriers to service provision for this population. No studies investigated the degree and nature of differences in outcomes between CALD and non-CALD stroke survivors with aphasia.

CONCLUSIONS

CALD stroke survivors with aphasia inconsistently access SLP services in hospital. Assessment is unlikely to be conducted in patient primary languages and therapy is usually provided in the language of SLPs. Further research is required to determine whether this impacts functional outcomes and health services.

Communication partner training with familiar partners of people with aphasia: A systematic review and synthesis of barriers and facilitators to implementation

BACKGROUND

Factors influencing the implementation of communication partner training (CPT) with familiar partners of people with aphasia (PWA) have previously been documented using disparate approaches. To date there has been no synthesis of these factors using a common theoretical framework. Investigating CPT implementation factors using a common theoretical framework may further our understanding of universal barriers and guide future development of tailored, theoretically informed implementation strategies.

AIMS

(1) To determine the perceived and/or observed barriers and facilitators to implementing CPT with familiar partners of adults with aphasia; (2) to map extracted barriers and facilitators to a common theoretical framework; (3) to synthesize extracted barriers and facilitators; and (4) to identify potential implementation strategies to address the most frequently identified barriers and facilitators.

METHODS & PROCEDURES

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four electronic databases (MEDLINE, EMBASE, CINAHL, Web of Science) were systematically searched in April 2021. Empirical qualitative and/or quantitative research studies reporting barriers/facilitators to speech-language therapists (SLTs) implementing CPT with familiar partners of adults with aphasia were included. The search was limited to English or French articles with no date limit applied. Methodological quality of included studies was assessed using the Mixed-Methods Appraisal Tool (MMAT). A framework and content analysis was then conducted to extract and synthesize the implementation factors in alignment with the Theoretical Domains Framework (TDF), followed by a theoretically informed mapping exercise to identify potential implementation strategies.

RESULTS & MAIN CONTRIBUTION

The database searches yielded 2115 studies. Following screening, 17 studies were included in the review. Overall, the included studies had good methodological quality. Extracted implementation factors were classified as barriers, facilitators or mixed (i.e., both) and aligned with 13 of the 14 TDF domains, plus two additional domains: 'carer perspectives on the CPT intervention' and 'patient/carer characteristics'. Synthesized data revealed eight key theoretical domains: Environmental context and resources; Social influences; Beliefs about consequences; Skills; Memory, attention and decision-making; Knowledge; Beliefs about capabilities; and Reinforcement. Within each domain, the research team identified common categories and developed illustrative examples of theoretically informed implementation strategies.

CONCLUSIONS & IMPLICATIONS

This systematic review and theory-informed synthesis of previously reported CPT implementation factors enabled the identification of key barriers to SLTs delivering this best practice. This led to proposed implementation strategies that should be validated, refined and evaluated in future research involving stakeholders who have contextual understanding of implementing CPT.

WHAT THIS PAPER ADDS

What is already known on the subject CPT of familiar partners of PWA is an effective intervention that is inconsistently used in clinical settings. Factors influencing CPT implementation have previously been identified, but using disparate approaches and frameworks. A synthesis of these factors articulated around a common framework is currently not available. What this paper adds to existing knowledge This paper provides a theory-informed synthesis of previously reported barriers and facilitators to SLTs implementing CPT with familiar partners of PWA. It highlights key factors influencing the uptake of this best practice and includes suggestion of implementation strategies to address them. What are the potential or actual clinical implications of this work? The key influencing factors and proposed implementation strategies reported in this paper may support stakeholders in the future design of tailored and theoretically informed implementation strategies aiming to improve the delivery of familiar CPT in their setting.

Examining Dose Frameworks to Improve Aphasia Rehabilitation Research

The effect of treatment dose on recovery of post-stroke aphasia is not well understood. Inconsistent conceptualization, measurement, and reporting of the multiple dimensions of dose hinders efforts to evaluate dose-response relations in aphasia rehabilitation research. We review the state of dose conceptualization in aphasia rehabilitation and compare the applicability of 3 existing dose frameworks to aphasia rehabilitation research-the Frequency, Intensity, Time, and Type (FITT) principle, the Cumulative Intervention Intensity (CII) framework, and the Multidimensional Dose Articulation Framework (MDAF). The MDAF specifies dose in greater detail than the CII framework and the FITT principle. On this basis, we selected the MDAF to be applied to 3 diverse examples of aphasia rehabilitation research. We next critically examined applicability of the MDAF to aphasia rehabilitation research and identified the next steps needed to systematically conceptualize, measure, and report the multiple dimensions of dose, which together can progress understanding of the effect of treatment dose on outcomes for people with aphasia after stroke. Further consideration is required to enable application of this framework to aphasia interventions that focus on participation, personal, and environmental interventions and to understand how the construct of episode difficulty applies across therapeutic activities used in aphasia interventions.

People with aphasia share their views on self-management and the role of technology to support self-management of aphasia

PURPOSE

Self-management can lead to increased self-efficacy and improved quality of life for individuals with chronic conditions; however, there is little research exploring how self-management approaches can be used for chronic communication disorders, such as aphasia. Modifications to self-management approaches would be required to accommodate for aphasia; therefore, the input of people with aphasia (PwA) should be sought. The aims of the present study were: (1) To investigate and document the experiences and perspectives of PwA regarding self-management; (2) To explore how technology can be used to support aphasia self-management.

MATERIALS AND METHODS

In-depth, semi-structured interviews were conducted with 26 PwA living in Australia. Qualitative content analysis was used to analyse interview data.

RESULTS

Analysis resulted in six themes: (1) In self-management, PwA take control of life with aphasia and assume responsibility for engaging in opportunities to improve overall communication; (2) Community aphasia groups are important enablers of self-management because they facilitate peer support; (3) Communication partners (CPs) provide multifaceted support in aphasia self-management; (4) SLPs provide integrated support and coordination in aphasia self-management; (5) Technology supports PwA to self-manage speech therapy and communication in daily life; (6) Psychological and physical health issues and societal factors may impact aphasia self-management abilities.

CONCLUSION

From the perspective of PwA, aphasia self-management involves enhancing skills enabling communication and life participation. PwA are central to aphasia self-management, with support provided by CPs, peers, and SLPs. Technology has a range of applications in aphasia self-management. PwA identified potential personal and contextual barriers that may impact self-management.IMPLICATIONS FOR REHABILITATIONFor people with aphasia, engaging in conversation and social interaction are primary means of managing/improving communicative life participation; therefore, this should be a key focus of aphasia self-management programs.Aphasia self-management approaches should maximise the use of available support and provide tailored information, education, and training in the area of self-management to key stakeholders (people with aphasia, communication partners, and speech-language pathologists).People with aphasia should be supported to use technology for aphasia self-management, encompassing communication specific and daily life use.People with aphasia should be heavily involved in the development of structured aphasia self-management approaches.

Management of communication disability in the first 90 days after stroke: a scoping review

INTRODUCTION

People with communication disability after stroke need interventions to optimise healthcare communication and rehabilitation outcomes. Current evidence syntheses do not adequately inform the management of communication disability during the first 90 days post-stroke.

PURPOSE

To explore the scope of literature for the management of communication disability in the first 90 days after stroke.

MATERIALS AND METHODS

A scoping review was conducted using a systematic keyword search of six databases. A descriptive synthesis was generated using communication-related domains related to the biopsychosocial framework of the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

A total of 129 studies met eligibility criteria. Aphasia was the most frequently addressed communication disability after stroke (76/129 studies) with a paucity of evidence investigating other acquired neurogenic communication impairments. Management predominantly focused on communication-related: body functions and structures (62 studies) (e.g., linguistic-behavioural therapies), followed by environmental factors (39 studies) (e.g., communication partner training/support); activities and participation (15 studies) (e.g., augmentative and alternative communication); and personal factors (13 studies) (e.g., assessment of depression after aphasia).

CONCLUSION

A coordinated, integrated approach to developing and testing acute and subacute interventions for all communication disabilities across all communication-related domains is required.IMPLICATIONS FOR REHABILITATIONInterdisciplinary stroke clinicians need to manage communication disabilities in the first 90 days after stroke to optimise healthcare communication and rehabilitation outcomes.There is some evidence to guide clinicians in aphasia management but less in other disabilities of speech and cognitive functioning.Most interventions to inform clinical practice address communication-related body functions and structures (e.g., linguistic and speech therapies). Clinicians need to address all domains and more evidence is needed to address environmental factors (e.g., communication support); activities and participation (e.g., person-centred goal setting); and personal factors (e.g., psychological care).

Characteristics and impacts of community aphasia group facilitation: a systematic scoping review

PURPOSE

Community aphasia groups (CAGs) can provide a range of benefits to people with aphasia and support long-term psychosocial wellbeing. However, the dominant speech-pathologist-led service delivery model is inherently limited in scope. Peer-led groups hold potential as a sustainable and empowering extension of this traditional model. The implementation of peer-led models likely requires targeted training and support, however little is known about the characteristics and impacts of CAG facilitation. This study reviews the literature on CAGs and their facilitation.

MATERIALS AND METHODS

We conducted a scoping review on this topic.

RESULTS

One hundred and seventy-seven texts were included, reporting on a heterogeneous range of activities. Most texts reported on speech-pathologist-led groups, however, a range of alternative models were also represented. While no studies directly compared the impacts of different facilitation models, some comparative benefits could be drawn from the literature. Facilitation was perceived as complex and challenging, and significant gaps were identified in the training of facilitators. Ten qualitative studies investigated characteristics and impacts of facilitator behaviours, providing a useful foundation for future development of training and evaluation tools.

CONCLUSIONS

Further investigation into alternative facilitation models and facilitator training needs will likely support the proliferation of high-quality CAGs.Implications for RehabilitationCommunity aphasia groups (CAGs) play an important role in supporting identity and wellbeing for individuals with chronic aphasia.The traditional speech-pathology led model of group service delivery is limited in scope; the addition of peer- and volunteer-led CAGs may facilitate access to groups and meet a range of different needs for individuals with aphasia.CAG facilitation is a complex and challenging task, likely requiring specialised training, however, this has not been widely available to facilitators.The development of specialised facilitator training will likely support the proliferation of sustainable and high-quality CAGs.

Communication partner perspectives of aphasia self-management and the role of technology: an in-depth qualitative exploration

PURPOSE

"Self-management" empowers individuals to take responsibility for their healthcare through skill-building, personal growth, and self-efficacy related to chronic health condition management. Self-management approaches may benefit people with aphasia (PwA); however, PwA are often excluded from stroke self-management research and there is no published research reporting on aphasia-specific self-management programs. Communication partners (CPs) are involved in the rehabilitation and day-to-day lives of PwA, thus giving them unique insights and knowledge of PwA needs. The present study aimed to investigate CP experiences and perspectives regarding aphasia self-management and to explore CP perceptions of the use of technology in aphasia self-management.

METHODS

In-depth, semi-structured interviews with 14 CPs living in Australia. Interview data was analysed using qualitative content analysis.

RESULTS

Analysis revealed six core themes: (1) aphasia self-management is embedded into everyday life, (2) CPs provide comprehensive self-management support, (3) speech-language pathologists (SLPs) provide tools and support to enable PwA to self-manage, (4) aphasia self-management can be enhanced by technological supports, (5) potential positive outcomes of aphasia self-management, and (6) factors influencing successful aphasia self-management.

CONCLUSIONS

Aphasia self-management programs should focus on individual needs, functional communication in daily life, and social interaction. PwA and CPs are central to these programs, assisted by SLPs. Technology should be explored to augment aphasia self-management.Implications for RehabilitationCommunication partners suggest that people with aphasia are already engaging in aspects of self-management and that more formal aphasia-specific self-management approaches may be beneficial.Dedicated aphasia self-management programs should be situated in daily life with a focus on functional communication, life participation, confidence, and independence.Communication partners, speech-language pathologists, and technology are key support sources for aphasia self-management.Further input should be sought from communication partners in the development of aphasia self-management programs.

Common Neuroanatomical Substrate of Cholinergic Pathways and Language-Related Brain Regions as an Explanatory Framework for Evaluating the Efficacy of Cholinergic Pharmacotherapy in Post-Stroke Aphasia: A Review

Despite the relative scarcity of studies focusing on pharmacotherapy in aphasia, there is evidence in the literature indicating that remediation of language disorders via pharmaceutical agents could be a promising aphasia treatment option. Among the various agents used to treat chronic aphasic deficits, cholinergic drugs have provided meaningful results. In the current review, we focused on published reports investigating the impact of acetylcholine on language and other cognitive disturbances. It has been suggested that acetylcholine plays an important role in neuroplasticity and is related to several aspects of cognition, such as memory and attention. Moreover, cholinergic input is diffused to a wide network of cortical areas, which have been associated with language sub-processes. This could be a possible explanation for the positive reported outcomes of cholinergic drugs in aphasia recovery, and specifically in distinct language processes, such as naming and comprehension, as well as overall communication competence. However, evidence with regard to functional alterations in specific brain areas after pharmacotherapy is rather limited. Finally, despite the positive results derived from the relevant studies, cholinergic pharmacotherapy treatment in post-stroke aphasia has not been widely implemented. The present review aims to provide an overview of the existing literature in the common neuroanatomical substrate of cholinergic pathways and language related brain areas as a framework for interpreting the efficacy of cholinergic pharmacotherapy interventions in post-stroke aphasia, following an integrated approach by converging evidence from neuroanatomy, neurophysiology, and neuropsychology.

Exploring How People with Expressive Aphasia Interact with and Perceive a Social Robot

People with aphasia need high-intensive language training to significantly improve their language skills, however practical barriers arise. Socially assistive robots have been proposed as a possibility to provide additional language training. However, it is yet unknown how people with aphasia perceive interacting with a social robot, and which factors influence this interaction. The aim of this study was to gain insight in how people with mild to moderate chronic expressive aphasia perceived interacting with the social robot NAO, and to explore what needs and requisites emerged. A total of 11 participants took part in a single online semi-structured interaction, which was analysed using observational analysis, thematic analysis, and post-interaction questionnaire. The findings show that participants overall felt positive towards using the social robot NAO. Moreover, they perceived NAO as enjoyable, useful, and to a lesser extent easy to use. This exploratory study provides a tentative direction for the intention of people with mild to moderate chronic expressive aphasia to use social robots. Design implications and directions for future research are proposed.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia

BACKGROUND

While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.

METHODS

We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.

RESULTS

We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.

CONCLUSIONS

CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.

TRIAL REGISTRATION NUMBER

ACTRN 2615000618550.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

PURPOSE

Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach.

METHOD

Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision.

RESULTS

Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery.

CONCLUSIONS

Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

How Do Clinicians Judge Fluency in Aphasia?

PURPOSE

Aphasia fluency is multiply determined by underlying impairments in lexical retrieval, grammatical formulation, and speech production. This poses challenges for establishing a reliable and feasible tool to measure fluency in the clinic. We examine the reliability and validity of perceptual ratings and clinical perspectives on the utility and relevance of methods used to assess fluency.

METHOD

In an online survey, 112 speech-language pathologists rated spontaneous speech samples from 181 people with aphasia (PwA) on eight perceptual rating scales (overall fluency, speech rate, pausing, effort, melody, phrase length, grammaticality, and lexical retrieval) and answered questions about their current practices for assessing fluency in the clinic.

RESULTS

Interrater reliability for the eight perceptual rating scales ranged from fair to good. The most reliable scales were speech rate, pausing, and phrase length. Similarly, clinicians' perceived fluency ratings were most strongly correlated to objective measures of speech rate and utterance length but were also related to grammatical complexity, lexical diversity, and phonological errors. Clinicians' ratings reflected expected aphasia subtype patterns: Individuals with Broca's and transcortical motor aphasia were rated below average on fluency, whereas those with anomic, conduction, and Wernicke's aphasia were rated above average. Most respondents reported using multiple methods in the clinic to measure fluency but relying most frequently on subjective judgments.

CONCLUSIONS

This study lends support for the use of perceptual rating scales as valid assessments of speech-language production but highlights the need for a more reliable method for clinical use. We describe next steps for developing such a tool that is clinically feasible and helps to identify the underlying deficits disrupting fluency to inform treatment targets.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19326419.

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Background

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Methods

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

Results

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis

Supplemental Digital Content is available in the text.

Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia.

Using experience-based codesign to coproduce aphasia rehabilitation services: study protocol

INTRODUCTION

Aphasia is an impairment of language that occurs in 30%-40% of stroke survivors. This often chronic condition results in poor outcomes for the individual with aphasia and their family. Long-term aphasia management is limited, with few people receiving sufficient services by 6-12 months postonset. We present a protocol for the development of coproduced aphasia service elements. We will use experience-based codesign (EBCD), an approach that enables service users and providers to collaboratively develop services and care pathways. Drawing on the experiences of people with aphasia, their families and clinicians we will establish priorities for the development of new services and later work together to codesign them.

METHODS AND ANALYSIS

This research will be coproduced with people with aphasia (n=30-60), their families (n=30-60) and speech pathologists (n=30-60) in Queensland, Australia, using EBCD. A consumer advisory committee will provide oversight and advice throughout the research. In phase 1, we will use semistructured interviews and the nominal group technique to explore experiences and unmet needs in aphasia rehabilitation. Data will be analysed using thematic analysis and the resulting themes will be prioritised in multistakeholder focus groups. Outcomes of phase 1 will inform future research (phase 2) to codesign services. Financial costs and participant experiences of EBCD will be measured.

ETHICS AND DISSEMINATION

Human Research Ethics Committee approval for phase 1 has been obtained (HREC/2020/QRBW/61368). Results will be reported in peer-reviewed journal articles, presented at relevant conferences and, following EBCD suggested best practice, fed back to participants and community members at a celebratory event at completion of the project. The inclusion of service users in all stages of research will facilitate an integrated approach to knowledge translation. A summary of research findings will be made available to participating sites.

Counseling in Aphasia: Information and Strategies for Speech-Language Pathologists

Purpose The purpose of this tutorial is to provide an overview of mental health concerns of persons with aphasia (PWAs), strategies that speech-language pathologists (SLPs) can use to address the mental health concerns of PWAs within their scope of practice, guidance related to how SLPs can help facilitate access to appropriate mental health services, and suggestions for the future of pre- and postcertification education regarding counseling in aphasia for SLPs. Method This tutorial begins with a case study that is used as a reference point throughout the tutorial. It then introduces the gap in mental health services for PWAs that prompted this work, walks SLPs through common mental health concerns PWAs experience, and provides guidance for SLPs related to counseling techniques they can utilize within their sessions and referral to counseling professionals. We end by reiterating the need for more mental health awareness and training for SLPs and suggestions for incorporating more training related to addressing client mental health concerns and developing effective collaborations with rehabilitation and mental health counselors, as needed. Conclusions The mental health needs of PWAs are not being met. This is partly due to a lack of training in counseling for SLPs and a lack of training in communication techniques for rehabilitation and mental health counselors. With this tutorial, we hope to bring more awareness to the current need for mental health services for PWAs and to provide SLPs with some tools for addressing these needs among their clientele.

The "Counseling+" Roles of the Speech-Language Pathologist Serving Older Adults With Mild Cognitive Impairment and Dementia From Alzheimer's Disease

Purpose

Persons with dementia and mild cognitive impairment (MCI) are major consumers of services provided by speech-language pathologists (SLPs). These services include not only direct assessment and treatment of communication and swallowing but also counseling, collaboration, prevention, and wellness. These "counseling+" activities can be especially challenging for SLPs to deliver because of the lack of evidence, as well as the complex nature of Alzheimer's disease (AD) and other conditions that cause MCI and dementia.

Method

This tutorial is written by a speech-language pathologist, a neuropsychologist, and a geriatric psychiatrist to provide education, resources, and recommendations for SLPs delivering counseling+ activities to patients with MCI and dementia from AD and related disorders.

Results and Conclusions

We describe counseling+ activities across the continuum of care ranging from educating and conducting cognitive screenings with adults experiencing age-related cognitive decline to supporting end-of-life wishes. Because of their expertise in communication, SLPs can provide an array of important leading and supporting services to patients, their family, and other health care professionals on the care team, such as providing patients with appropriate feedback following a cognitive screening and helping caregivers identify the communicative intent of a responsive behavior. The demand for SLP services for patients with MCI and dementia will grow significantly over the next few decades, necessitating more systematic research and clinical evidence in this area.

Exploring the relationship between fatigue and circulating levels of the pro-inflammatory biomarkers interleukin-6 and C-reactive protein in the chronic stage of stroke recovery: A cross-sectional study

Background

The precise mechanisms underlying the aetiology of post-stroke fatigue remain poorly understood. Inflammation has been associated with clinically significant fatigue across a number of neurological disorders; however, at present there is a lack of evidence regarding the association of fatigue and inflammation in the chronic phase of stroke recovery.

Aims

The aim of this study was to examine fatigue in a cohort of stroke survivors in the chronic phase of stroke, compared with matched controls, and to explore associations between the pro-inflammatory cytokine interleukin-6, high-sensitivity C-reactive Protein and fatigue.

Methods

We performed an exploratory cross-sectional study of 70 people in the chronic phase of stroke recovery, and 70 age matched controls. Fatigue was assessed using the Fatigue Assessment Scale. Interleukin-6 was measured in serum using a commercially available enzyme immunoassay kit. Both outcome measures were assessed contemporaneously.

Results

Clinically significant fatigue, defined as a score ≥24 on the Fatigue Assessment Scale, was reported by 60% of stroke survivors, and 15.7% of controls. The odds of experiencing clinically significant fatigue was 8.04 times higher among stroke survivors compared to control participants (odds ratio 8.045; 95% CI: 3.608, 17.939; P ​< ​0.001). The fatigue score was significantly correlated with the level of both interleukin-6 and high-sensitivity c-reactive protein, however once entered into a linear regression model with cardiovascular covariables, this relationship was no longer statistically significant.

Conclusions

This study shows that fatigue may be associated with systemic inflammation in the chronic phase of stroke. The pathological mechanisms underlying post-stroke fatigue and its clinical implications require further study.

Aphasia-Diagnostic Challenges and Trends: Speech-Language Pathologist's Perspective

Objectives

To explore current aphasia assessment practices and barriers among Pakistani speech language pathologists.

Methods

Descriptive study design with qualitative parameters was used. Participants were identified using purposive sampling over a period of eight months from 1st December 2018 to 31st July 2019. Sample comprised of ten speech-language pathologists with least five years' experience of working with aphasic clients from four major cities of Pakistan including Islamabad, Karachi, Lahore and Peshawar. Study included in depth interviews using a self-structured interview guide with probe questions. Data recorded was transcribed and thematic analyses were drawn manually.

Results

Thematic analysis revealed that most Speech language pathologists rely heavily on informal assessment techniques. With no aphasia assessment tool available in Urdu language, no consensus as to the optimal evaluation strategy or tool for aphasia assessment was noted. However, need for such tool was highlighted by all participants. Hence, non-availability of standardized and culturally appropriate assessment tool in "Urdu" language turned out to be the major barrier in adopting formal assessment for aphasic clients, while time consumed in formal testing remained second most reported issue.

Conclusion

There is a dire need of quick aphasia assessment tool in Urdu language with established psychometric properties and culturally appropriate norms.

Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions

PURPOSE

Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP.

METHODS

Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis.

RESULTS AND CONCLUSIONS

17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).

Developments in the application of Intensive Comprehensive Aphasia Programs: an international survey of practice

PURPOSE

Intensive Comprehensive Aphasia Programs (ICAPs) were first described in 2013 with an international survey documenting 12 unique programs. ICAPs involve high dose intervention delivered in both group and individual settings, targeting communication across impairment, functioning, participation, and contextual domains. In this study, we aimed to investigate international growth in ICAPs.

MATERIALS AND METHODS

We developed a 43-item questionnaire expanding on the original 2013 version to investigate program modifications, activities, protocolised therapies, software and apps, and family involvement. The survey was disseminated to aphasia clinicians and researchers internationally (November 2019-February 2020).

RESULTS

Thirty-nine unique respondents completed the survey from nine countries. Twenty-one met the criteria for an ICAP or modified ICAP (mICAP): 14 ICAPs; 7 mICAPs, and 13 of these were new programs. ICAPs differed from mICAPs with greater emphasis on group sessions, use of technology, total communication, advocacy, and art activities. A large range of protocolised therapies were used across programs. An increased focus on mood and psychosocial well-being was observed compared to the 2013 survey.

CONCLUSIONS

The number and comprehensiveness of ICAPs has grown since 2013 with development of modified versions. Future research should focus on comparative efficacy of ICAPs/mICAPs and other forms of aphasia interventions and factors underpinning growth and sustainability.Implications for RehabilitationClinicians who coordinate or are considering commencing an ICAP in future can use these results to consider the design of their program.Coordinators should carefully consider the components of their ICAPs and advise consumers whether they meet the definition of an ICAP or a mICAP.With the increasing number of ICAPs across the globe, clinicians commencing an ICAP may wish to contact existing ICAPs within their country for advice.Program sustainability may be challenging and these results provide an indication of some of the key challenges coordinators may face.

'I hated being ghosted' - The relevance of social participation for living well with post-stroke aphasia: Qualitative interviews with working aged adults

Background

In the context of increasing incidence of stroke in working aged adults, there is a specific need to explore the views of working aged adults with post‐stroke aphasia, whose communication difficulties may result in restricted social participation, loss of employment and changed relationship and parenting roles. This study aimed to explore the perspectives of working aged adults with post‐stroke aphasia in relation to social participation and living well with aphasia (LWA).

Design and participants

We conducted qualitative interviews with 14 people with post‐stroke aphasia (PWA). Data were analysed following principles of reflexive, thematic analysis.

Patient or Public Contribution: A Public and Patient Involvement aphasia advisory group inputted into the study design and interpretation of data.

Results

Social participation spanned 5 themes: Relationships and roles; Social support; Peer network, Aphasia awareness; and Employment and training. Meaningful, interesting social participation for LWA is individually defined. Working aged PWA may require flexible support with parenting, accessing a diverse social network and finding opportunities for meaningful social connection, training and employment.

Conclusions

The findings extend knowledge of social participation in the context of LWA for working aged adults by elucidating the individually defined nature of meaningful participation and how PWA may need flexible support with parenting, accessing a diverse social network and training and employment. For aphasia research, policy and services to be relevant, it is crucial that working aged PWA are meaningfully involved in setting the aphasia agenda.

Speech-language pathologists' perceptions and experiences when working with Aboriginal and Torres Strait Islander children

PURPOSE

This study explored the perceptions of speech-language pathologists with regards to culturally responsive service delivery, assessment practices, and confidence when working with Aboriginal and Torres Strait Islander children.

METHOD

An online survey was used. Descriptive statistics were analysed with SPSS. Themes were derived from text responses using Braun and Clarke's thematic analysis method.

RESULT

The 48 respondents were almost all non-Indigenous, equally spread across metropolitan and non-metropolitan regions, and had varied levels of experience. Respondents reported moderate to high levels of confidence. Identified barriers included accessibility, policy, impacts of colonisation, awareness of services and expectations and speech pathologist knowledge, training and experience. Engagement emerged as a facilitator to provision of culturally responsive services. A variety of speech-language pathology assessment methods were reported, not all of which were consistent with current recommendations.

CONCLUSION

Identified barriers and facilitators were consistent with previous research exploring work with adults with acquired communication disorders. A need to explore the perspectives of Aboriginal and Torres Strait Islander communities as users of speech-language pathology services was identified. Clinical implications are described for future training, clinical guidelines, and flexible service delivery.

Prognostication in post-stroke aphasia: speech pathologists' clinical insights on formulating and delivering information about recovery

PURPOSE

For people with post-stroke aphasia, "Will I get better?" is a question often asked, but one that is intellectually and emotionally demanding for speech pathologists to answer. Speech pathologists' formulation and delivery of aphasia prognoses is varied and there is limited evidence for optimising practice. We aimed to understand speech pathologists' clinical experiences, reasoning, and support needs in aphasia prognostication.

MATERIALS AND METHODS

Twenty-five Australian speech pathologists working with people with aphasia participated in individual, semi-structured interviews. Their age, level of experience, work setting, and location were maximally varied. Interview responses were analysed qualitatively using thematic analysis.

RESULTS

Five themes were drawn from the interviews: (1) prognostic challenges are shared but not voiced; (2) truth is there's no quick fix; (3) recovery is more than words; (4) the power of words; and, (5) prognostic competence is implicit.

CONCLUSIONS

Speech pathologists use implicit competencies to formulate and deliver aphasia prognoses. A patient-centred, holistic contextualisation of aphasia recovery may enable realistic, optimistic, and constructive conversations about prognosis. These conversations may have therapeutic potential if prognostic uncertainty, emotional adjustment, and conditional outcomes are carefully addressed. Future research should seek to understand the perceptions and preferences of people with aphasia and their significant others.Implications for RehabilitationAphasia prognostication in clinical practice is complex and nuanced, thus increased clinical and research focus is warranted to ensure key stakeholder needs are met.Conversations about prognosis may be more meaningful to people with aphasia if recovery is conceptualised as encompassing impairment, activity, and participation outcomes.Given the implicit competencies required for prognostication, a structured approach to reflective practice and experience-based training may be beneficial.Conversations about prognosis may have therapeutic value, but further research is needed to explore this potential.

"It's really exciting to think where it could go": a mixed-method investigation of clinician acceptance, barriers and enablers of virtual reality technology in communication rehabilitation

PURPOSE

Acquired communication disorders can result in significant barriers to everyday life activities, and commonly require long-term rehabilitation. This research aimed to investigate usability, acceptance, barriers and enablers to the use of immersive virtual reality (VR) technology for communication rehabilitation from the perspective of speech-language pathologists (SLPs).

METHODS

Semi-structured interviews and surveys (system usability and motion sickness) were carried out with 15 SLPs following their participation in communication activities typical of daily life, experienced within an immersive VR kitchen environment.

RESULTS

The system usability scores were average. In addition, motion sickness symptoms were low after interaction with the VR system. The main findings from semi-structured interviews are discussed across five main themes: (i) attitude towards the use of VR in communication rehabilitation (ii) perceived usefulness of VR (iii) perceived ease of use of VR (iv) intention to use VR, and (v) clinical adoption barriers and enablers.

CONCLUSIONS

Overall, participants were positive about VR and its potential applications to communication rehabilitation. This study provides a foundation to inform the design, development, and implementation of a VR system to be used in the rehabilitation of individuals with acquired communication disorders.IMPLICATIONS FOR REHABILITATIONVirtual Reality applications could simulate social communication situations within the clinic.VR could be used as a rehabilitation tool for communication assessment and/or outcome measure.VR requires customisation to the specific communication rehabilitation needs of the client.Participants identified barriers and enablers to adoption of VR by speech-language pathologists.

When interactions are interruptions: an ethnographic study of information-sharing by speech and language therapists and nurses on stroke units

PURPOSE

To explore how the information-sharing context influences how speech and language therapy (SLT) and nursing staff interact on stroke units and what they discuss.

METHODS

Ethnographic methodology was used, with data collected during 40 weeks of fieldwork across three inner city stroke units in the UK. Data comprised field notes collected during 357 h of participant observation and 43 interviews. Interviews were conducted with 14 SLTs, 1 SLT assistant, 24 registered nurses and 4 nursing assistants.

RESULTS

This paper is focused on informal information-sharing. SLTs and nurses had different experiences of time and space (the temporal-spatial context) with respect to ward presence and proximity to patients, influencing how they interacted, the content of their talk and their relationships. Most interactions had the quality of interruptions, in which SLTs seized moments in between nursing tasks. Conditions were less suited to sharing information about communication than swallowing and SLTs felt more allied to other therapists than nurses.

CONCLUSION

The temporal-spatial context impeded information-sharing, particularly about patients' communication needs. Consideration should be given to developing relationships between SLTs and nurses as key partners for patient care and raising the profile of communication information in ways that are relevant and useful to nursing work.Implications for rehabilitationStrategic waiting for opportunities to interrupt nurses and gain their attention is central to how speech and language therapists manage their need to share information informally with nurses.The small "windows in time" available for interaction influence information-sharing, with a limiting effect on information about patients' communication.There is potential to improve information-sharing between speech and language therapists and nurses by considering how the relevance of information for patient care could be made clearer.

The relevance of stroke care for living well with post-stroke aphasia: a qualitative interview study with working-aged adults

PURPOSE

This study aimed to explore the perspectives of working-aged adults with post-stroke aphasia (PWA) towards what has or would help them in living well with aphasia (LWA). This paper reports the findings in relation to stroke care and its relevance for LWA.

MATERIALS AND METHODS

This qualitative study was designed with input from a Public and Patient Involvement advisory group. We conducted in-depth, semi-structured interviews with 14 PWA. Data were analysed following principles of reflexive thematic analysis.

RESULTS

Support services and LWA spanned five themes: Inpatient care; Support in the community; Speech therapy; Mental health; and Aphasia education and training. Per the findings, all aspects of stroke care were affected and challenged by aphasia. Access to services and information was variable. PWA of working-age, their families and children need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery. Healthcare workers must be equipped with aphasia competency.

CONCLUSIONS

The results highlight a need for equitable, transparent, responsive access to services, information and stroke liaison support. The findings extend knowledge of the importance of stroke care for supporting working-aged adults and their families to live well in the context of aphasia.Implications for rehabilitationThere is a need for equitable, transparent access to a responsive integrated pathway of stroke care to support living well with aphasia.People with aphasia post-stroke and their families need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery.This includes flexible access to mental healthcare and speech and language therapy.In order to access relevant care, people with post-stroke aphasia need access to information and stroke liaison support.Training to improve aphasia competency is imperative for healthcare workers.

Barriers and facilitators to implementing stepped psychological care for people with aphasia: Perspectives of stroke health professionals

Background Concomitant aphasia and depression after stroke is highly prevalent, but there is a lack of psychological care in stroke rehabilitation for people with aphasia and family members. Evidence-based frameworks such as stepped psychological care may be viable, but the barriers and facilitators to translating this framework into aphasia rehabilitation practice are unknown.Aim The aim of this study was to identify, from the perspective of stroke health professionals, the barriers and facilitators to implementing stepped psychological care for depression after post-stroke aphasia.Method Five semi-structured focus groups of stroke health professionals were conducted (n = 39) across the stroke care continuum. Verbatim transcripts were analyzed using Interpretive Description.Results Barriers and facilitators were identified within three core themes: knowledge, skills, and attitudes have the most impact on implementing stepped psychological care; the physical environment impacts on managing depression and communication disability for people with aphasia; and the support and leadership of the health organization influence change in any implementation of a stepped psychological care approach. Barriers included: no experience with stepped psychological care; limited understanding of aphasia and communication support; lack of adequate physical space and resources; lack of psychologists. Facilitators included: specialist training; enhancement of physical spaces; communication tools; leadership; funding; specialized staff.Conclusion Addressing the identified barriers and facilitators to stepped psychological care will improve the viability of implementing this evidence-based framework after post-stroke aphasia. Change may be driven through specialist training for health professionals in communication support; mood assessment and treatments; modification of physical space; and accessible resources.

Dose effects in behavioural treatment of post-stroke aphasia: a systematic review and meta-analysis

PURPOSE

Aphasia is a debilitating chronic acquired language disorder that impacts heavily on a person's life. Behavioural treatments aim to remediate language processing skills or to enhance communication between the person with aphasia and others, and a number of different treatments are efficacious. However, it is unclear how much of a particular treatment a person needs in order to optimise recovery of language and communication skills following stroke.

MATERIALS AND METHODS

Systematic search for and meta-analysis of experimental studies that directly compared different amounts of the same behavioural aphasia treatment, following PRISMA guidelines.

RESULTS

Treatment dose research in aphasia is an emerging area. Just six studies comparing different doses of the same intervention met all criteria for inclusion. Evidence from these studies was synthesised and meta-analysed, where possible. Meta-analyses were inconclusive due to limited data; however, there are indications that suggest increased dose may confer greater improvement on language and communication measures, but with diminishing returns over time. Aphasia severity and chronicity may affect dose-response relationships.

CONCLUSIONS

There is currently insufficient evidence to determine the effect of dose on treatment response. A dedicated and coordinated research agenda is required to systematically explore dose-response relationships in post-stroke aphasia interventions.A video abstract is available in the Supplementary Material.Implications for rehabilitationThe investigation of the effect of dose on treatment outcomes in post-stroke aphasia is an emerging research area with few studies reporting comparison of different amounts of the same intervention.In the acute phase of recovery following stroke, higher doses of treatment provided over short periods may not be preferable, tolerable, or superior to lower doses of the same treatment.In the chronic phase, providing additional blocks of treatment may confer additional benefit for some people with aphasia but with diminishing returns.People with chronic aphasia can achieve and maintain significant gains in picture naming after a relatively brief period of high-dose treatment.

Supporting people with post-stroke aphasia to live well: A cross-sectional survey of Speech & Language Therapists in Ireland

Living well with post-stroke aphasia is supported by responsive, collaborative heath and related services, aphasia information and training for people with aphasia (PWA) and their social networks, and opportunities to contribute and participate autonomously in their communities. Several international surveys indicate shortcomings in the provision of long-term support and, in Ireland, while there is a lack of data around service provision for PWA, there is evidence that post-acute stroke services are fragmented and under-resourced. The aim of this study was to survey Speech & Language Therapists (SLTs), due to their unique role in aphasia management, to understand what SLT and related support services and aphasia information and training are currently available to support living well with aphasia in Ireland. We developed and piloted a self-administered, web-based cross-sectional survey with questions informed by a systematic review and qualitative evidence synthesis around living well with aphasia, and with input from a Public and Patient Involvement aphasia advisory group. Data from 95 SLTs working with PWA were analysed using descriptive statistics. Although SLT was generally available for PWA, the results highlight access barriers and evidence-practice gaps in terms of the amount, intensity and timing of SLT to be maximally effective and there was a lack of PWA input into service design and evaluation. Access to other relevant supports such as mental health services was inconsistent and there was a lack of community support for families. There were shortcomings in access to aphasia information/training for PWA, families, friends and other healthcare professionals. There is a need for a coordinated and standardised approach to supporting PWA across Ireland. This study addresses an evidence gap around the provision of stroke services for PWA and is part of a larger project aiming to produce recommendations for improving person-centred support to facilitate living well with aphasia.

Dysphagia screening using an allied health assistant delegation model: service considerations for implementation

PURPOSE

Three facilities, involved in introducing a model of Allied Health Assistant (AHA) delegated dysphagia screening, examined barriers and facilitators to service implementation.

MATERIALS AND METHODS

The 3 facilities varied in size, services and location. AHAs (n = 4) and speech-language therapists (SLTs; n = 4) directly involved in implementation at each site completed semi-structured interviews exploring the implementation experience. Analysis was guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

There was differential implementation across the sites. Facilitators to implementation fell within the CFIR Innovation Characteristic domain, with the "relative advantage" of the model and "design, quality and packaging" of the training and implementation resources being key facilitators. Barriers related to the Innovation Characteristic domain, regarding the tool's "adaptability" in terms of screening tools selected and the implementation environment. Issues with the Inner Setting domain, specifically the "structural characteristics," the "compatibility" of the model and the "relative priority" of the model's implementation within other organizational priorities were also barriers.

CONCLUSIONS

Although the service model was perceived to have relative advantage, compatibility with local work-flow priorities and service needs must be thoroughly considered if AHA delegated dysphagia screening is to be beneficial as a service model to address increasing dysphagia referral demands.IMPLICATIONS FOR REHABILITATIONDysphagia is a disabling condition which may result in medical, social and operational complications.The demands of screening, assessing, managing and providing rehabilitation for dysphagia are increasing, therefore alternative models of service delivery including delegation are increasingly being considered and implemented.This study provides evidence regarding the context and facilitators of successful AHA dysphagia screening model implementation.This evidence contributes to a growing knowledge base of delegation practices for the management of staffing resources and building of capacity for rehabilitation service delivery.

Friendships after severe traumatic brain injury: a survey of current speech pathology practice

OBJECTIVE

To investigate current speech pathology practice regarding working with friends.

METHOD

An online survey was conducted with 68 speech pathologists who worked with TBI across metropolitan and rural settings in Australia. The survey investigated the reasons speech pathologists work with friends, barriers to working with friends and perceptions of successful friendships post TBI. Descriptive statistics and content analysis of open ended responses were used to analyze the data.

RESULTS

There were more speech pathologists (40%) who did not include friends compared to those who did. Friends were most commonly included in the rehabilitation process, through the provision of education programs. The primary rationale for working with friends was to prevent negative psychosocial outcomes for the person with TBI. There were numerous barriers to working with friends, most commonly the inability to access friends.

CONCLUSIONS

Making and keeping friends are a significant part of most people's lives. Therefore, it is important to consider their role in contributing to improved outcomes for people with TBI. With communication partner training being an integral component to recovery and maintenance of relationships post TBI, the development of targeted education and training materials is warranted, to enable the inclusion of friends in the rehabilitation process.

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

PRIMARY OBJECTIVE

To explore the clinical practice of communication partner training by Speech and Language Therapists for people with traumatic brain injury in the UK.

STUDY DESIGN

Online 97-item survey which addressed the practice of training both familiar and unfamiliar communication partners, and barriers and facilitators to implementation informed by the Theoretical Domains Framework.

PARTICIPANTS

169 Speech and Language Therapists from private and public settings in the UK.

RESULTS

While 96% reported training familiar communication partners, only 58% reported training unfamiliar communication partners. Therapists reported providing communication partner training consistent with best practice 43% of the time. Evidence-based published programmes were used by 13.8% and 19.9% of participants for training familiar and unfamiliar partners, respectively. Therapists reported using outcomes for familiar and unfamiliar communication partners 83% and 78% of the time. The most frequently reported barrier was lack of behavioral regulation (e.g., planning). Most frequent perceived facilitators were clinicians wanting to deliver communication partner training and that training was part of therapists' professional role (social professional role and identity).

CONCLUSIONS

Therapists were motivated to deliver communication partner training but reduced capability affected implementation. Further support to clinicians on outcome measurement with materials to develop workplace systems to monitor implementation is needed.

Participant reported outcomes of a community of practice about social participation for speech-language pathologists in aphasia rehabilitation

Purpose: Because of their communication difficulties, persons with aphasia are at risk of not fully participating in significant activities after rehabilitation. Speech-language pathologists can contribute to support optimal social participation in rehabilitation. A community of practice (CoP) was designed to provide motivated clinicians with opportunities to acquire knowledge and reflect on social participation within aphasia rehabilitation. The aim of this study was to describe the outcomes of this CoP according to the perspectives of speech-language pathologist participants.Methods: Semi-structured individual interviews were conducted 4 to 10 weeks after the end of the CoP with 13 speech-language pathologist participants. Analyses were guided by grounded theory.Results: Participants perceived that the CoP experience contributed to a better alignment of their practice with the ideal end purpose of optimizing social participation. A sense of community emerged among CoP members, who collectively reflected on their practice. Participants stated feeling equipped to adopt new practices, adopting new practices for optimizing social participation, and/or advocating for better services for persons with aphasia. They felt increased confidence, motivation, well-being, and/or energy towards their practice.Conclusions: CoPs can help speech-language pathologists to more confidently practice with the goal of optimizing the social participation of persons with aphasia.Implications for rehabilitationSpeech-language pathologists in aphasia rehabilitation, as a result of being involved in a community of practice (CoP) about social participation, may offer more evidence-based services aiming at optimizing the social participation of persons with aphasia.Markers of a successful CoP may include participants' increased feelings of confidence, motivation, well-being, and/or energy towards their practice.CoPs can be used for continuing education purposes and support the development of clinical expertise among professionals, such as speech-language pathologists in aphasia rehabilitation.