Conversation Therapy with People with Aphasia and Conversation Partners using Video Feedback: A Group and Case Series Investigation of Changes in Interaction

Measuring successful conversations in couples with and without aphasia: A scoping review

BACKGROUND

Aphasia impacts communication and relationships. While counselling is increasingly recognised as a component of the speech-language therapy role, the success of conversation partner training is typically measured in terms of communication alone. This scoping review aimed to describe how successful conversation is currently measured with couples-with and without aphasia, to inform the development of an ecologically valid measure for couples with aphasia.

METHODS AND PROCEDURES

The scoping review was reported in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extensions for Scoping Reviews (PRISMA-SCR). MEDLINE, EMBASE, CINAHL and PsycINFO databases were searched for conversation treatment studies for couples with and without aphasia. Patient-reported outcome measures (PROMs) were extracted from included studies and screened against the three-tier model of situated language to shortlist those that measure everyday communication. Items within shortlisted PROMs were further described using the refined International Classification of Functioning, Disability and Health linking rules.

RESULTS

Following screening and full-text review, 46 studies were included, consisting of 24 studies conducted with couples with aphasia and 22 studies conducted with couples without aphasia. For couples with aphasia, 13 PROMs were identified that measured everyday communication. Of these, 23% were dyadic (i.e., measured from the perspectives of both members of the couple); however, they usually only appraised the communication behaviours of the person with aphasia. For couples without aphasia, eight PROMs were identified that measured everyday communication; all were dyadic and measured both attitudes and communication behaviours of both partners.

CONCLUSION

Conversation relies on the interaction of two people, and success in conversation is best rated by those having the conversation. The use of PROMs is recommended as part of person and relationship-centred practice; however, there is currently no validated PROM for conversation in aphasia that considers the perspectives and behaviours of both the person with aphasia and their communication partner. The PROM items identified in this study will form the basis of future research to develop a PROM for couples' conversations in aphasia.

WHAT THIS PAPER ADDS

What is already known on the subject Communication partner training (CPT) for couples, where one person has aphasia, can improve conversation skills and enhance relationships. Clinician-rated measures, such as conversation analysis, have been used to measure the outcomes of CPT. However, there is a lack of person-centred or self-rated outcome measurement instruments. that is, patient-reported outcome measures (PROMs) for couples' conversations in aphasia. What this paper adds to existing knowledge We have identified outcome measurement instruments used in conversation treatment studies for couples with and without aphasia. We found that most PROMs used in aphasia treatment studies were not dyadic, that is, they did not include the self-report of both communication partners. In contrast, the PROMs used with couples without aphasia were dyadic and contained items that measured a more complex range of both partners' emotions, behaviours and attitudes. What are the potential or actual clinical implications of this work? This study provides insights into the content and characteristics of PROMs for couples' conversation therapy and may assist clinicians in selecting outcome measurement instruments in their practice.

Towards efficient, ecological assessment of interaction: A scoping review of co-constructed communication

BACKGROUND

The complexity of communication presents challenges for clinical assessment, outcome measurement and intervention for people with acquired brain injury. For the purposes of assessment or treatment, this complexity is usually managed by isolating specific linguistic functions or speech acts from the interactional context. Separating linguistic functions from their interactional context can lead to discourse being viewed as a static entity comprised of discrete features, rather than as a dynamic process of co-constructing meaning. The ecological validity of discourse assessments which rely on the deconstruction of linguistic functions is unclear. Previous studies have reported assessment tasks that preserve some of the dialogic features of communication, but as yet, these tasks have not been identified as a distinct genre of assessment. We suggest the term 'co-constructed communication' to describe tasks which are specifically designed to capture the dynamic, jointly produced nature of communication within a replicable assessment task.

AIMS

To identify and summarize how co-constructed communication has been assessed with individuals with non-progressive acquired communication disability regarding task design, measures and psychometric robustness.

METHODS

A scoping review methodology was used to identity relevant studies. Systematic database searches were conducted on studies published before July 2021. Studies in the yield were assessed against eligibility criteria, with 37 studies identified as eligible for inclusion.

MAIN CONTRIBUTION

This is the first time that co-constructed communication has been defined as a genre of discourse assessment for stroke and traumatic brain injury populations. Co-constructed communication has been assessed for 144 individuals with aphasia and 111 with cognitive-communication disability. Five categories of co-constructed communication tasks were identified, ranging in complexity. Variability exists in how these assessment tasks are labelled and measured. Assessment measures require further psychometric profiling, specifically regarding test-retest reliability and validity.

CONCLUSIONS

Co-constructed communication is a discourse genre which offers researchers and clinicians a replicable method to assess language and communication in an experimentally rigorous way, within an ecologically valid context, bridging the gap between experimental and ecological assessment approaches.

WHAT THIS PAPER ADDS

What is already known on this subject Standardized assessments of language skills and monologue offer reliable, replicable ways to measure language. However, isolating language from an interactional context fundamentally changes the behaviour under study. This raises questions about the ecological validity of the measures we routinely use to determine diagnoses, guide treatment planning and measure the success of treatment. What this study adds to the existing knowledge This review highlights studies that conceptualize, and often quantify, interaction by combining experimental rigour and aspects of everyday dialogue. This is the first time this genre of discourse assessment has been identified. We propose the term 'co-constructed communication' to describe this genre and provide an operational definition for the term. What are the practical and clinical implications of this study? Co-constructed communication assessment tasks require refinement, particularly regarding aspects of psychometric robustness. In the future, these tasks offer pragmatic, meaningful ways to capture the effect and impact of aphasia and cognitive-communication disability within interaction.

Development of fidelity of delivery and enactment measures for interventions in communication disorders

OBJECTIVES

This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted.

DESIGN

Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study.

METHODS

A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group.

RESULTS

Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale.

CONCLUSIONS

This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions.

Conversation Analysis Based Simulation (CABS): A method for improving communication skills training for healthcare practitioners

BACKGROUND

Actors portraying simulated patients are widely used in communication skills training in healthcare, but debates persist over the authenticity of these interactions. However, healthcare professionals value simulation-based training because of the opportunity to think and react in real time, which alternatives cannot provide.

OBJECTIVE

To describe a method for the use of simulation which maximises authenticity by grounding training in real, observed, patterns of patient communication.

DESIGN

Naturally occurring care interactions were video recorded and analysed using conversation analysis (CA) to identify communication patterns. We focused on sites of recurring interactional trouble as areas for training, and identified more and less effective ways of dealing with these. We used the CA findings to train actors portraying simulated patients, based on the observed interactional patterns.

SETTINGS AND PARTICIPANTS

Patients living with dementia and healthcare practitioners (HCPs) on two acute healthcare of the elderly wards in the English East Midlands.

OUTCOME MEASURES

One month later HCPs reported using the skills learned in clinical practice. Masked-ratings of before and after simulated patient encounters confirmed these self-reports in relation to one key area of training.

RESULTS

The Conversation Analysis Based Simulation (CABS) method used in this setting showed positive results across a range of quantitative and qualitative outcome measures. What is significant for the transferability of the method is that qualitative feedback from trainees highlighted the ability of the method to not only illuminate their existing effective practices, but to understand why these were effective and be able to articulate them to others.

DISCUSSION/CONCLUSION

While the CABS method was piloted in the dementia care setting described here, it has potential applicability across healthcare settings where simulated consultations are used in communication skills training. Grounding simulated interaction in the observed communication patterns of real patients is an important means of maximising authenticity.

PATIENT AND PUBLIC CONTRIBUTION

The VideOing to Improve dementia Communication Education (VOICE) intervention which piloted the CABS method was developed by a multidisciplinary team, including three carers of people with dementia. People living with dementia were involved in the rating of the before and after video simulation assessments.

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.

A bibliometrix-based visualization analysis of international studies on conversations of people with aphasia: Present and prospects

In recent years, there has been a rapid increase in the number of people with aphasia due to brain lesions worldwide, which has prompted researchers to carry out in-depth studies on the pathogenesis, inducement and prognosis of aphasia from neurology, clinical medicine, psychology and other disciplines. With the deepening of research and understanding of aphasia, it is generally believed that a single discipline can no longer meet the needs of the academic community. Therefore, multidisciplinary integration has emerged and achieved fruitful results. This paper, based on the biblioshiny package run by R, conducts bibliometric analysis on the international interdisciplinary research status of conversation and aphasia, predicts its future development direction, and provides reference for relevant domestic research from international source journals. The results indicate that led by Australia, the United Kingdom, the United States and other countries, the international conversational aphasia research has formed a complete system, and formed a "descriptive study of patients with language disorders" and "applied study of rehabilitation treatment". In the future, while continuing to focus on these two categories of research, the empathy ability of conversational partners and medical staff may be taken into account, in order to better contribute to improving patients' quality of life.

Results from a randomised controlled pilot study of the Better Conversations with Primary Progressive Aphasia (BCPPA) communication partner training program for people with PPA and their communication partners

BACKGROUND

There has been a growing focus on functional communication interventions for primary progressive aphasia (PPA). These interventions aim to support individuals to participate in life situations. One such intervention, communication partner training (CPT) aims to change conversation behaviours in both the person with PPA and their communication partner (CP). CPT has a growing evidence base in stroke aphasia; however, these programmes are not designed to meet the needs of people with progressive communication difficulties. To address this, the authors developed a CPT program entitled Better Conversations with PPA (BCPPA) and undertook a pilot trial to establish for a future full trial; predicted recruitment rates, acceptability, an assessment of treatment fidelity and an appropriate primary outcome measure.

METHODOLOGY

This was a single-blind, randomised controlled pilot study comparing BCPPA to no treatment, delivered across 11 National Health Service Trusts in the UK. A random sample of eight recordings of local collaborators delivering the intervention were analysed to examine fidelity. Participants completed feedback forms reporting on acceptability. Pre- and post-intervention measures targeted conversation behaviours, communication goals and quality of life.

RESULTS

Eighteen people with PPA and their CPs (9 randomised to BCPPA, 9 randomised to no treatment) completed the study. Participants in the intervention group rated BCPPA positively. Treatment fidelity was 87.2%. Twenty-nine of 30 intervention goals were achieved or over-achieved and 16 of 30 coded conversation behaviours demonstrated change in the intended direction. The Aphasia Impact Questionnaire was identified as the preferred outcome measure.

CONCLUSION

The first randomised controlled UK pilot study of a CPT program for people with PPA and their families demonstrates BCPPA is a promising intervention. The intervention was acceptable, treatment fidelity high and an appropriate measure identified. Results of this study indicate a future RCT of BCPPA is feasible.

TRIAL REGISTRATION

Registered 28/02/2018 ISRCTN10148247 .

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41416.

Toward Neurodiversity: How Conversation Analysis Can Contribute to a New Approach to Social Communication Assessment

PURPOSE

The purpose of this clinical focus article was to illustrate the potential of employing conversation analysis (CA) as a method for assessing social communication that is neurodiversity affirming.

METHOD

This clinical focus article will provide an overview of CA and explain how it offers a theoretically grounded means of analyzing autistic children's everyday social interactions. Our aim is not simply to add a new assessment instrument to the disciplinary toolbox but to use the occasion to spur a reconsideration of how social communicative competence is currently conceptualized in the field and how those assumptions are reified through assessment practices. We will present a case illustration of a bilingual autistic child and his family. We will discuss the implications of a CA-informed assessment for reconceptualizing autistic social communicative competence.

RESULTS

The case study illustrates the contributions of CA for (a) shifting the focus of assessment from social communication as an individual skill to social communication as an interactional achievement and (b) surfacing social communicative competencies that may be dismissed as pathologies.

CONCLUSIONS

CA offers a relational understanding of autistic communication and sociality that is compatible with a critical stance on disability. Insights from CA problematize deeply entrenched notions of autism and social communication in speech-language pathology.

Better conversations: a language and communication intervention for aphasia in posterior cortical atrophy

Posterior cortical atrophy (PCA) describes a neurodegenerative syndrome characterized by progressive difficulties in cortical visual and other posterior cortical functions consistent with parieto-occipital and occipito-temporal involvement. It is increasingly recognized that many patients develop difficulties with other aspects of daily living, in particular, with language and communication. We present a case emphasizing how language difficulties may emerge in PCA. Difficulties are interpreted as arising from interacting effects of linguistic deficits and impaired detection of nonverbal (particularly, visual) turns that normally facilitate, schedule, and disambiguate the exchange of verbal messages between speakers. We propose that relatively simple speech and language therapy interventions may hold promise in addressing language and communication difficulties as secondary features of PCA by targeting the behaviors of both the person with PCA and their communication partners.

"If You Just Stay With Me and Wait…You'll Get an Idea of What I'm Saying": The Communicative Benefits of Time for Conversational Self-Repair for People With Aphasia

PURPOSE

This study investigated the communicative benefits of self-repair during conversation for persons with aphasia (PWAs). Self-repair of trouble sources is an interactional priority that emphasizes autonomy and competence. Of equal importance, conversationalists desire to minimize silences and work together to ensure forward movement (progressivity) of conversation. Simultaneously achieving progressivity and self-repair is challenging in aphasia, and PWAs and their partners often make trade-off decisions between these two activities. Conversation-level aphasia interventions usually focus on supportive techniques that promote participation while maintaining progressivity, effectively favoring progressivity over self-repair. This study evaluates the benefits of an alternative approach that shifts the emphasis to self-repair, thereby highlighting potential trade-off costs of routinely forgoing self-repair to achieve progressivity.

METHOD

Ten people with mild-to-moderate aphasia each held two conversations with two different partners. When trouble sources characterized by silent and/or filled pauses occurred, partners maintained a supportive and engaged stance, allowing PWAs time to self-repair. We analyzed language produced during these "edited turns" using three paradigms considering form, content, and use.

RESULTS

The data yielded 311 edited turns. For form, on average, each edited turn resulted in 3.72 words; for content, most edited turns contained autobiographical information; for use, approximately 40% of edited turns introduced new information, and 40% added to the ongoing topic. The remainder were either ambiguous or comments such as, "I can't think of it."

CONCLUSIONS

When given engaged support and time to self-repair, PWAs contributed meaningful personal information to conversations for approximately 80% of edited turns. Importantly, self-repair often resulted in self-expression that directed the conversation, which is a communicative role critical for empowering agency and identity. This research opens a dialogue about benefits and limitations of approaches that prioritize either progressivity or self-repair and how to balance the two to optimize therapeutic benefits for each individual.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19379738.

Using the Medical Research Council framework and public involvement in the development of a communication partner training intervention for people with primary progressive aphasia (PPA): Better Conversations with PPA

Background

Primary progressive aphasia is a language-led dementia resulting in a gradual dissolution of language. Primary progressive aphasia has a significant psychosocial impact on both the person and their families. Speech and language therapy is one of the only available management options, and communication partner training interventions offer a practical approach to identify strategies to support conversation. The aim of this study was to define and refine a manual and an online training resource for speech and language therapists to deliver communication partner training to people with primary progressive aphasia and their communication partners called Better Conversations with primary progressive aphasia.

Methods

The Better Conversations with primary progressive aphasia manual and training program were developed using the Medical Research Council framework for developing complex interventions. The six-stage development process included 1. Exploratory review of existing literature including principles of applied Conversation Analysis, behaviour change theory and frameworks for chronic disease self-management, 2. Consultation and co-production over 12 meetings with the project steering group comprising representatives from key stakeholder groups, 3. Development of an initial draft, 4. Survey feedback followed by a consensus meeting using the Nominal Group Techniques with a group of speech and language therapists, 5. Two focus groups to gather opinions from people with PPA and their families were recorded, transcribed and Thematic Analysis used to examine the data, 6. Refinement.

Results

Co-production of the Better Conversations with primary progressive aphasia resulted in seven online training modules, and a manual describing four communication partner training intervention sessions with accompanying handouts. Eight important components of communication partner training were identified in the aggregation process of the Nominal Group Technique undertaken with 36 speech and language therapists, including use of video feedback to focus on strengths as well as areas of conversation breakdown. Analysis of the focus groups held with six people with primary progressive aphasia and seven family members identified three themes 1) Timing of intervention, 2) Speech and language therapists’ understanding of types of dementia, and 3) Knowing what helps. These data informed refinements to the manual including additional practice activities and useful strategies for the future.

Conclusions

Using the Medical Research Council framework to develop an intervention that is underpinned by a theoretical rationale of how communication partner training causes change allows for the key intervention components to be strengthened. Co-production of the manual and training materials ensures the intervention will meet the needs of people with primary progressive aphasia and their communication partners. Gathering further data from speech and language therapists and people living with primary progressive aphasia and their families to refine the manual and the training materials enhances the feasibility of delivering this in preparation for a phase II NHS-based randomised controlled pilot-feasibility study, currently underway.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02561-8.

Transcranial Direct-Current Stimulation May Improve Discourse Production in Healthy Older Adults

Background: The use of transcranial direct-current stimulation (tDCS) for therapeutic and neurorehabilitation purposes has become increasingly popular in recent years. Previous research has found that anodal tDCS may enhance naming ability and verbal fluency in healthy participants. However, the effect of tDCS on more functional, higher level language skills such as discourse production has yet to be understood. Aims: The present study aimed to investigate in healthy, older adults (a) the effect of anodal tDCS on discourse production vs. sham stimulation and (b) optimal electrode placement for tDCS to target language improvement at the discourse level. Methods: Fourteen healthy, older right-handed participants took part in this sham controlled, repeated measures pilot study. Each participant experienced three different experimental conditions; anodal tDCS on the left inferior frontal gyrus (IFG), anodal tDCS on the right IFG and sham stimulation while performing a story telling task. Significant changes in language performance before and after each condition were examined in three discourse production tasks: recount, procedural and narrative. Results: Left and right IFG conditions showed a greater number of significant within-group improvements (p < 0.05) in discourse production compared to sham with 6/12 for left IFG, 4/12 for right IFG and 2/12 for sham. There were no significant differences noted between tDCS conditions. No relationship was noted between language performance and physical activity, age, or gender. Conclusions: This study suggests that anodal tDCS may significantly improve discourse production in healthy, older adults. In line with previous tDCS language studies, the left IFG is highlighted as an optimal stimulation site for the modulation of language in healthy speakers. The findings support further exploration of tDCS as a rehabilitative tool for higher-level language skills in persons with aphasia.

Searching for active ingredients in rehabilitation: applying the taxonomy of behaviour change techniques to a conversation therapy for aphasia

PURPOSE

A taxonomy of behaviour change techniques has been developed to help specify the active ingredients of behaviour change interventions. Its potential for rehabilitation research is significant, however, reliable use among allied health professionals has not yet been explored. This article describes the content of a conversation therapy for post-stroke aphasia using the taxonomy and investigates inter-rater reliability among Speech and Language Therapists.

METHODS AND MATERIALS

Two Speech and Language Therapists undertook the same half day, self-led training programme in the behaviour change technique taxonomy and independently coded all materials in the "Better Conversations with Aphasia" programme. Inter-rater reliability was evaluated using the kappa coefficient and percentage agreement. Reliably agreed techniques were categorised according to the speaker and type of behaviour they targeted.

RESULTS

Sixteen behaviour change techniques were reliably agreed to be present. Inter-rater reliability was moderate (K = 0.465), and in line with satisfactory percentage agreement (79.8%). More techniques were used to target the adoption of new behaviours (15) than the termination of old ones (3). People with aphasia received fewer behaviour change techniques (10) than their communication partners (16).

CONCLUSIONS

Describing the content of conversation therapy with the taxonomy of behaviour change techniques offers clinically useful insights with potential to enhance both research and practice. The intervention is shown to target different types of behaviour in different ways, and offer different speaker groups different content. Non-psychologist users of the taxonomy may encounter challenges working with unfamiliar concepts and terminology, which may impact on reliable use.IMPLICATIONS FOR REHABILITATIONIn order to change communicative behaviours within conversation, feedback should focus not only on performance but also on the immediate social and emotional consequences of a behaviour.This study adds to the evidence that unhelpful conversational behaviours can be reduced by providing speakers with information about any unwanted consequences, and then agreeing on a supportive behaviour to use instead.People with aphasia should be offered the same range of behaviour change techniques as their communication partners.

A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study

Background

Twenty-five per cent of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Health-care professionals report a lack of communication skills training.

Objectives

To identify teachable, effective strategies for communication between health-care professionals and people living with dementia, and to develop and evaluate a communication skills training course.

Design

We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using coproduction and multiple pedagogic approaches. We ran a pilot, followed by six courses for health-care professionals. We measured knowledge, confidence and communication behaviours before, immediately after and 1 month after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations.

Setting

General hospital acute geriatric medical wards and two hospital clinical skills centres.

Participants

We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six health-care professionals took part in a pilot course, and 45 took part in the training.

Results

The literature review identified 26 studies describing 10 communication strategies, with modest evidence of effectiveness. Health-care professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask) and with lowered contingencies (made to sound less difficult, by minimising the extent or duration of the task, asking patients ‘to try’, offering help or proposing collaborative action). Closings were more successful if the health-care professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised 2 days, 1 month apart, using experiential learning, including lectures, video workshops, small group discussions, simulations (with specially trained actors) and reflections. We emphasised the incorporation of previous expertise and commitment to person-centred care. Forty-four participants returned for the second training day and 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was rated highly in interviews, especially the use of simulations, real-life video clips and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them 1 month after the course finished.

Limitations

Data were from people with moderate to severe dementia, in an acute hospital, during health-care professional-initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias.

Conclusions

Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality.

Future work

Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of health-care communication.

Study registration

The systematic literature review is registered as CRD42015023437.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Using conversation analysis to inform role play and simulated interaction in communications skills training for healthcare professionals: identifying avenues for further development through a scoping review

BACKGROUND

This paper responds to previously published debate in this journal around the use of sociolinguistic methods in communication skills training (CST), which has raised the significant question of how far consultations with simulated patients reflect real clinical encounters. This debate concluded with a suggestion that sociolinguistic methods offer an alternative analytic lens for evaluating CST. We demonstrate here that the utility of sociolinguistic methods in CST is not limited to critique, but also presents an important tool for development and delivery.

METHODS

Following a scoping review of the use of role play and simulated interaction in CST for healthcare professionals, we consider the use of the specific sociolinguistic approach of conversation analysis (CA), which has been applied to the study of health communication in a wide range of settings, as well as to the development of training.

DISCUSSION

Role play and simulated interaction have been criticised by both clinicians and sociolinguists for a lack of authenticity as compared to real life interactions. However they contain a number of aspects which healthcare professionals report finding particularly useful: the need to think on one's feet in real time, as in actual interaction with patients; the ability to receive feedback on the simulation; and the ability to watch and reflect on how others approach the same simulation task in real time. Since sociolinguistic approaches can help to identify inauthenticity in role play and simulation, they can also be used to improve authenticity. Analysis of real-life interactions using sociolinguistic methods, and CA in particular, can identify actual interactional practices that are used by particular patient groups. These practices can then be used to inform the training of actors simulating patients. In addition, the emphasis of CA on talk as joint activity means that proper account can be taken of the way in which simulated interaction is co-constructed between simulator and trainee. We suggest that as well as identifying potential weaknesses in current role play and simulation practice, conversation analysis offers the potential to enhance and develop the authenticity of these training methods.

The 'Better Conversations with Primary Progressive Aphasia (BCPPA)' program for people with PPA (Primary Progressive Aphasia): protocol for a randomised controlled pilot study

Background

Primary progressive aphasia is a language-led dementia, often associated with frontotemporal dementia. It presents as insidious deterioration of language skills (e.g. naming objects and understanding complex sentences), with relative sparing of cognitive skills initially. There is little research examining the effectiveness of communication skills training for primary progressive aphasia, yet speech and language therapists (SLTs) report regularly using this in clinical practice. ‘Better Conversations with Primary Progressive Aphasia’ has potential to reduce barriers and increase facilitators to conversation and consequently improve confidence in communication and quality of life for people living with primary progressive aphasia and their conversation partners. The aim of this pilot study is to examine the feasibility of running a trial of the ‘Better Conversations with Primary Progressive Aphasia’ intervention.

Methods

A single blind, randomised controlled pilot study will recruit 42 participants with primary progressive aphasia and their conversation partners across seven UK National Health Service Trusts. Participants will be randomised on a 1:1 basis, stratified by site, to receive either the ‘Better Conversations with Primary Progressive Aphasia’ intervention (21 couples) or no speech and language therapy treatment (21 couples). Participants are recruited by SLTs who will conduct pre-intervention assessment (week 1) and deliver the intervention (weeks 2 to 5). Junior researchers, who are blinded to allocation, will complete post-intervention measures (week 6). SLTs complete 9 h of training to prepare them to deliver the intervention. The primary objective of the study is to establish for a phase III effectiveness study whether the program can be delivered as intended in a UK National Health Service setting. Specifically, it will establish (1) the acceptability of randomisation, (2) an assessment of treatment fidelity to determine necessary levels of SLT training, (3) the most appropriate primary outcome measure, (4) sample size requirements, (5) predicted patient recruitment and retention rates and (6) refined inclusion criteria.

Discussion

Insights from this study will be of relevance to guide development of future research and in particular, trials of therapeutic interventions in PPA, as well as for clinical care for this population.

Trial registration

Retrospectively registered 28/02/2018 ISRCTN10148247

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0349-6) contains supplementary material, which is available to authorized users.

Interaction-focussed therapy for aphasia: Effects on communication and quality of life

PURPOSE

This study examined the effects of an interaction-focussed therapy for aphasia, which involved both people with aphasia and their familiar conversation partners. It was hypothesised the interaction-focussed therapy would lead to positive changes in targeted conversation behaviours, and improved quality of life for participants with aphasia.

METHOD

Three people with chronic aphasia and three of their familiar conversation partners completed an 8-week interaction-focussed therapy programme. A series of single case multiple-baseline ABA experiments were conducted. Outcome measures focussed on changes in targeted behaviours between pre- and post-therapy conversation samples, and changes in quality of life.

RESULT

All participant dyads improved their conversations. Familiar conversation partners demonstrated significant changes in targeted behaviours, while only one participant with aphasia achieved significant improvements. There was little evidence of a positive impact on quality of life for participants with aphasia.

CONCLUSION

Interaction-focussed therapy enhances everyday communication for people with aphasia and their conversation partners. However, the complex nature of learning in this intervention means that further, likely interdisciplinary work is required to better understand what mediates skill acquisition and therapeutic change and its psychosocial impact. This information is particularly important for optimising interaction-focussed therapy for people with aphasia.

The paradox of helping: Contradictory effects of scaffolding people with aphasia to communicate

When interacting with people with aphasia, communication partners use a range of subtle strategies to scaffold, or facilitate, expression and comprehension. The present article analyses the unintended effects of these ostensibly helpful acts. Twenty people with aphasia and their main communication partners (n = 40) living in the UK were video recorded engaging in a joint task. Three analyses reveal that: (1) scaffolding is widespread and mostly effective, (2) the conversations are dominated by communication partners, and (3) people with aphasia both request and resist help. We propose that scaffolding is inherently paradoxical because it has contradictory effects. While helping facilitates performing an action, and is thus enabling, it simultaneously implies an inability to perform the action independently, and thus it can simultaneously mark the recipient as disabled. Data are in British English.