Intersectionality and Its Relevance in the Context of Aboriginal People with Brain Injury in Australia.

In this article, we explore the benefits of recognizing the impact of intersectionality on access to, and provision of, brain injury care in a First Nations context. While disadvantage and discrimination are often associated with the intersection of culture, gender, disability, and socioeconomic disadvantage, it is only when these factors are explored together that clinicians can really understand what people need to recover and thrive following acquired brain injury. In this article, we challenge speech-language pathologists to examine their own practices, to look beyond Western models of health and constraints of many current institutional models of care and ways of framing research, to acknowledge historical and ongoing colonizing influences, and to engage with community-led solutions. We provide a model of Aboriginal-led care, where intersection of discrimination and marginalization is minimized and the multiple components of the individual, carers/communication partners, and the environment become empowering factors instead.

Investigation of the implementation of a Communication Enhanced Environment model on an acute/slow stream rehabilitation and a rehabilitation ward: A before-and-after pilot study.

OBJECTIVES: Develop and implement a Communication Enhanced Environment model and explore its effect on language activities for patients early after stroke. METHOD AND DESIGN: Before-and-after pilot study. SETTING: An acute/slow stream rehabilitation and a rehabilitation ward in a private hospital in Perth, Western Australia. PARTICIPANTS: Fourteen patients recruited within 21 days of stroke. Seven recruited during the before-phase (control group: patients with aphasia = 3, patients without aphasia = 4) and seven recruited in the after-phase (intervention group: patients with aphasia = 4, patients without aphasia = 3). INTERVENTION: The intervention group exposed to a Communication Enhanced Environment model had access to equipment, resources, planned social activities and trained communication partners. Both groups received usual stroke care. DATA COLLECTION: Hospital site champions monitored the availability of the intervention. Behavioural mapping completed during the first minute of each 5-minute interval over 12 hours (between 7 am and 7 pm) determined patient engagement in language activities. RESULTS: Seventy-one percent of the Communication Enhanced Environment model was available to the intervention group who engaged in higher, but not significant (95% CI), levels of language activities (600 of 816 observation time points, 73%) than the control group (551 of 835 observation time points, 66%). Unforeseen reorganisation of the acute ward occurred during the study. CONCLUSIONS: Implementation of a Communication Enhanced Environment model was feasible in this specific setting and may potentially influence patients' engagement in language activities. The unforeseen contextual challenges that occurred during the study period demonstrate the challenging nature of the hospital environment and will be useful in future research planning.

An exploration of aphasia therapy dosage in the first six months of stroke recovery.

Aphasia research uses the length of time within rehabilitation sessions as the main measure of dosage. Few papers detail therapeutic ingredients or outline the number of times these were delivered over the treatment period. The present observational study identified therapeutic ingredients in the Very Early Rehabiltiation in SpEech (VERSE) trial and explored the dosage provided using a model of cumulative intervention intensity (CII). Therapists video recorded one therapy session per week and 53 (12%) randomly selected therapy videos were analysed. The videos were coded for number of error productions, self-corrections and type and frequency of therapist cueing. The Western Aphasia Battery Revised-Aphasia Quotient (WABR-AQ) was used for measuring patient outcome with total verbal utterances (p < 0.001) and cues used with success (p < 0.001) being independent positive predictors of WABR-AQ score at six months post stroke and hypothesized as key therapeutic ingredients. The CII was calculated by counting identified therapeutic ingredients and multiplying this by the number of sessions completed. Collectively, the key ingredients occurred on average 504 times per session and over 10,000 times per participant during the treatment period. This paper reports a novel approach for identifying key treatment ingredients and detailing the dosage delivered within an early aphasia rehabilitation trial.

Evaluation of the Allied Health Rural Generalist Program 2017-2019.

OBJECTIVE: To evaluate the development and implementation of the Allied Health Rural Generalist Program, a two-level online post-graduate education program, which includes Level 1, an entry-level non-award pathway program, and Level 2, a Graduate Diploma in Rural Generalist Practice. DESIGN: A convergent mixed methodology evaluation in two overlapping stages: a process evaluation on quality and reach, together with a mixed method case study evaluation on benefits, of the program. SETTING: Rural and remote Australia across ten sites and seven allied health professions: dietetics; occupational therapy; pharmacy; physiotherapy; podiatry; radiography; speech pathology. PARTICIPANTS: Process evaluation included 91 participants enrolled in all or part of the Rural Generalist Program. Case study evaluation included 50 managers, supervisors and Rural Generalist Program participants from the ten study sites. INTERVENTIONS: The Allied Health Rural Generalist Program. MAIN OUTCOME MEASURES: Process evaluation data were derived from enrolment data and education evaluation online surveys. Case study data were gathered via online surveys and semi-structured interviews. Quantitative and qualitative data were collected concurrently, analysed separately and then integrated to identify consistency, expansion or discordance across the data. RESULTS: The Rural Generalist Program was viewed as an effective education program that provided benefits for Rural Generalist Program participants, employing organisations and consumers. Key improvements recommended included increasing profession-specific and context-specific content, ensuring Rural Generalist Program alignment with clinical and project requirements, strengthening support mechanisms within employing organisations and ensuring benefits can be sustained in the long term. CONCLUSION: The Rural Generalist Program offers a promising strategy for building a fit-for-purpose rural and remote allied health workforce.

Does Direct Helicopter Retrieval Improve Survival of Severely Injured Trauma Patients From Rural Western Australia?

OBJECTIVE: In remote Western Australia, mortality from major trauma is more than 4 times higher than mortality rates from major trauma in the capital city of Perth. The objective of this study was to determine whether direct helicopter emergency medical service (HEMS) retrieval from an incident scene within the zone 50 to 250 km of Perth to a tertiary hospital improves survival in severely injured trauma patients. Direct HEMS retrieval was compared with indirect retrieval whereby patients were transferred by ambulance to a nearby rural hospital before retrieval to a tertiary hospital in Perth. METHODS: A retrospective analysis (2006-2015) was undertaken of all Western Australia trauma registries, and coronial data were collected for all major trauma patients who died before retrieval to a tertiary hospital in Perth. RESULTS: A total of 1,374 major trauma patients (indirect retrieval = 1,031 and direct HEMS = 343) met the study inclusion criteria. There was a 51% increased risk of death in the indirect patients compared with the direct HEMS patients (15.3% vs. 10.2%, P ≤ .001). CONCLUSION: Direct HEMS retrieval from the incident scene to a tertiary hospital substantially improves the chances of survival for severely injured trauma patients in rural locations in the zone 50 to 250 km of Perth.

Missing Voices: Profile, Extent, and 12-Month Outcomes of Nonfatal Traumatic Brain Injury in Aboriginal and Non-Aboriginal Adults in Western Australia Using Linked Administrative Records.

OBJECTIVE: To investigate differences in the profile and outcomes between Aboriginal and non-Aboriginal Western Australians (WAs) hospitalized with traumatic brain injury (TBI). SETTING: WA hospitals. PARTICIPANTS: TBI cases aged 15 to 79 years surviving their first admission during 2002-2011. DESIGN: Patients identified from diagnostic codes and followed up for 12 months or more using WA-wide person-based linked hospital and mortality data. MAIN MEASURES: Demographic profile, 5-year comorbidity history, injury mechanism, injury severity, 12-month readmission, and mortality risks. Determinants of 12-month readmission. RESULTS: Of 16 601 TBI survivors, 14% were Aboriginal. Aboriginal patients were more likely to be female, live remotely, and have comorbidities. The mechanism of injury was an assault in 57% of Aboriginal patients (vs 20%) and transport in 33% of non-Aboriginal patients (vs 17%), varying by remoteness. One in 10 Aboriginal TBI patients discharged themselves against medical advice. Crude 12-month readmission but not mortality risk was significantly higher in Aboriginal patients (48% vs 36%). The effect of age, sex, and injury mechanism on 12-month readmission was different for Aboriginal and non-Aboriginal patients. CONCLUSION: These findings suggest an urgent need for multisectoral primary prevention of TBI, as well as culturally secure and logistically appropriate medical and rehabilitation service delivery models to optimize outcomes.

Aspects of speech-language abilities are influenced by MECP2 mutation type in girls with Rett syndrome.

This study investigates relationships between methyl-CpG-binding protein 2 gene (MECP2) mutation type and speech-language abilities in girls with Rett syndrome. Cross-sectional data on 766 girls, aged 15 years and under, with genetically confirmed Rett syndrome was obtained from the Australian Rett Syndrome Database (ARSD) (n = 244) and the International Rett Syndrome Phenotype Database (InterRett) (n = 522). Relationships between MECP2 mutation type and age of regression in speech-language abilities, and the level of speech-language abilities before and after this regression were investigated. The females had a median age of 4.95 years in the ARSD and 5.25 years in InterRett. The majority (89%, 685/766) acquired speech-language abilities in the form of babble or words at some point in time. Of those who acquired babble or words, 85% (581/685) experienced a regression in these abilities. Those with a p.Arg133Cys mutation were the most likely to use one or more words, prior to (RRR = 3.45; 95% CI 1.15-10.41) and after (RRR = 5.99; 95% CI 2.00-17.92), speech-language regression. Girls with Rett syndrome vary in their use of speech and language, and in their experience of speech-language regression and these variations are partly explained by genotype.

A comparison of aphasia therapy outcomes before and after a Very Early Rehabilitation programme following stroke.

BACKGROUND: Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results. AIMS: To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months). METHODS & PROCEDURES: This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models. OUTCOMES & RESULTS: After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants. CONCLUSIONS & IMPLICATIONS: A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy.

Utilisation of simulation-based learning to decrease student anxiety and increase readiness for clinical placements for speech-language pathology students.

PURPOSE: To investigate the use of two versions of a simulation-based learning experience (SBLE) to decrease speech-language pathology (SLP) students' anxiety and increase their confidence and sense of preparedness for clinical placements. METHOD: Two cohorts of third-year SLP students (n = 33) participated in a mixed-methods study with each cohort completing one version of the SBLE. Participants completed pre- and post-program quantitative ratings of anxiety, confidence, and preparedness for clinical placements and participated in focus groups. Three clinical educators also provided qualitative data in debriefs and interviews. RESULT: Significant decreases in student ratings of anxiety, and increases in confidence and sense of preparedness, were found for participants from both versions of the SBLE. No significant differences were found between changes in each measure between the two groups. Qualitative data from the student focus groups and clinical educator interviews described affective changes in the students, which concurred with the quantitative results. CONCLUSION: Results suggest this SBLE can be used to improve SLP students' self-perceptions of readiness for clinical placements. Comparable outcomes can be achieved for students using the shorter, less resource intensive version of the SBLE program, with reduced costs, to overcome barriers to its implementation.

Amount of therapy matters in very early aphasia rehabilitation after stroke: a clinical prognostic model.

BACKGROUND AND AIM: The effects of very early aphasia therapy on recovery are equivocal. This article examines predictors of very early aphasia recovery through statistical modeling. METHODS: This study involved a secondary analysis of merged data from two randomized, single-blind trials conducted in Australian acute and subacute hospitals. Study 1 (n = 59) compared daily therapy to usual ward care for up to 4 weeks poststroke in patients with moderate to severe aphasia. Study 2 (n = 20) compared daily group therapy to daily individual therapy for 20 1-hour sessions over 5 weeks, in patients with mild to severe aphasia. The primary outcome measure was the Western Aphasia Battery Aphasia Quotient (AQ) at therapy completion. This analysis used regression modeling to examine the effects of age, baseline AQ and baseline modified Rankin Scale (mRS), average therapy amount, therapy intensity, and number of therapy sessions on aphasia recovery. RESULTS: Baseline AQ (p = 0.047), average therapy amount (p = 0.030), and baseline mRS (p = 0.043) were significant predictors in the final regression model, which explained 30% (p < 0.001) of variance in aphasia recovery. CONCLUSION: The amount of very early aphasia therapy could significantly affect communication outcomes at 4 to 5 weeks poststroke. Further studies should include amount of therapy provided to enhance reliability of prognostic modeling in aphasia recovery.

Communication services for First Nations peoples after stroke and traumatic brain injury: Alignment of Sustainable Development Goals 3, 16 and 17.

PURPOSE: Colonisation and continuing discrimination have significantly and negatively impacted the physical, social and emotional wellbeing of First Nations peoples globally. In Australia, Aboriginal cultures thrive despite ongoing barriers to health care. This paper describes challenges and new initiatives for Australian Aboriginal people with acquired communication disability after brain injury and their alignment with the global aims forming the Sustainable Development Goals. RESULT: Research undertaken by an Aboriginal and non-Aboriginal multidisciplinary team over a decade in Western Australia identified and responded to mismatches between community needs and services. Initiatives described include the Missing Voices, Healing Right Way, Brain Injury Yarning Circles and Wangi/Yarning Together projects. Recommendations implemented related to (a) greater incorporation of Aboriginal cultural protocols and values within services, (b) more culturally secure assessment and treatment tools, (c) support after hospital discharge, (d) Aboriginal health worker involvement in support. Implementation includes cultural training of hospital staff, trialling new assessment and treatment methods, and establishing community-based Aboriginal Brain Injury Coordinator positions and relevant peer support groups. CONCLUSION: Culturally secure brain injury rehabilitation in Australia is in its infancy. Our initiatives challenge assumptions about worldviews and established Western biomedical models of healthcare through incorporating Indigenous methodologies and leadership, and community-driven service delivery. This commentary paper focuses on Sustainable Development Goals 3, 16 and 17.

Community-based early intervention for language delay: a preliminary investigation.

BACKGROUND: A trial parent-focused early intervention (PFEI) programme for children with delayed language development is reported in which current research evidence was translated and applied within the constraints of available of clinical resources. The programme, based at a primary school, was run by a speech-language pathologist with speech-language pathology students. AIM: To investigate the changes in child language development and parent and child interactions following attendance at the PFEI. METHODS & PROCEDURES: Eighteen parents and their children attended six, weekly group sessions in which parents were provided with strategies to maximize language learning in everyday contexts. Pre- and post-programme assessments of vocabulary size and measures of parent-child interaction were collected. OUTCOME & RESULTS: Parents and children significantly increased their communicative interactions from pre- to post-treatment. Children's expressive vocabulary size and language skills increased significantly. Large-effect sizes were observed. CONCLUSIONS & IMPLICATIONS: The positive outcomes of the intervention programme contribute to the evidence base of intervention strategies and forms of service delivery for children at risk of language delay.

Expressing opinions and feelings in a conversational setting.

This article examines the ways in which individuals with aphasia communicate opinions and feelings using evaluative language during conversation in an aphasia group. Evaluative language refers to semantic resources conveying emotions, judgments, and valuations and includes emotive adjectives, nouns, verbs, and adverbs as well as metaphor. Although individuals with aphasia are known to be able to use evaluative language in a monologic context, little is known about how people with aphasia use evaluative language in conversation, or about the role of co-construction in such usage. The data for this study were collected during a conversation group consisting of five participants with aphasia and a facilitator. The analysis used is based on Appraisal theory (Martin and White 2005) and examined the evaluation categories of Affect, Appreciation, Judgment, and Graduation. Regardless of severity, all aphasic speakers contributed an equal amount of evaluation to the interaction and demonstrated some usage of all types of evaluation. However, those with more severe aphasia relied heavily on their conversational partners to scaffold their opinions and used a range of resources including lexical items, such as exactly, and repetition (e.g., "yeah yeah yeah") to agree emphatically with opinions expressed. Lexical variety was notably less in the aphasic speakers than the non-brain-damaged group facilitator. The article discusses the patterns of skills observed together with the clinical implications for working with people with aphasia on emotional meanings.

Staff and volunteers' perceptions of a Communication Enhanced Environment model in an acute/slow stream rehabilitation and a rehabilitation hospital ward: a qualitative description study within a before-and-after pilot study.

PURPOSE: A lack of social interaction during early stroke recovery can negatively affect neurological recovery and health-related quality of life of patients with aphasia following stroke. A Communication Enhanced Environment (CEE) model was developed to increase patient engagement in language activities early after stroke. This study aimed to examine staff (n = 20) and volunteer (n = 2) perceptions of a CEE model and factors influencing the implementation and use of the model. This study formed part of a broader study that developed and embedded a CEE model on two hospital wards. MATERIALS AND METHODS: Six focus groups and one interview with hospital staff were conducted and analysed using a qualitative description approach. Feedback emailed by volunteers was included in the data set. RESULTS: Staff and volunteers perceived the CEE model benefitted themselves, the hospital system and patients. Staff identified a range of factors that influenced the implementation and use of the CEE model including individual staff, volunteer and patient factors, hospital features, the ease with which the CEE model could be used, and the implementation approach. CONCLUSIONS: This study provides valuable insights into staff perceptions which may inform the implementation of interventions and future iterations of a CEE model.Implications for RehabilitationA CEE model may promote efficiency and increased patient engagement in stroke rehabilitation.The CEE model information session and aphasia communication partner training, and the provision of resources, may be useful strategies to increase staff confidence in using communication supporting strategies with patients with aphasia.Behaviour change and implementation science strategies may provide a framework to address barriers and promote facilitators to embed hospital-based interventions that require individual, ward, cultural and systems level change to reduce the evidence-based gap in clinical practice.

Patients' experiences of a Communication Enhanced Environment model on an acute/slow stream rehabilitation and a rehabilitation ward following stroke: a qualitative description approach.

BACKGROUND: Patients in hospital following stroke express a desire to continue therapy tasks outside of treatment activities. However, they commonly describe experiences of boredom and inactivity. An enriched environment aims to provide opportunities for physical, cognitive and social activity and informed the development of a Communication Enhanced Environment (CEE) model to promote patient engagement in language activities. PURPOSE: Explore patient perceptions of a CEE model, and barriers and facilitators to engagement in the model. METHODS: A qualitative description study from a larger project that implemented a CEE model into acute and rehabilitation private hospital wards in Western Australia. Semi-structured interviews were conducted with seven patients, including four with aphasia, within 22 days post-stroke who had access to the CEE model. RESULTS: Patients described variable experiences accessing different elements of the CEE model which were influenced by individual patient factors, staff factors, hospital features as well as staff time pressures. Those who were able to access elements of the CEE model described positive opportunities for engagement in language activities. CONCLUSIONS: While findings are encouraging, further exploration of the feasibility of a CEE model in this complex setting is indicated to inform the development of this intervention.Implications for rehabilitationPatient access to a CEE model is challenging in a hospital setting.Patients who were able to access elements of the CEE model described positive opportunities for engagement in language activities.Patients' access to the CEE model was influenced by patient factors, staff factors, hospital features as well as staff time pressures.

Treatment fidelity monitoring, reporting and findings in a complex aphasia intervention trial: a substudy of the Very Early Rehabilitation in SpEech (VERSE) trial.

BACKGROUND: Treatment fidelity is inconsistently reported in aphasia research, contributing to uncertainty about the effectiveness of types of aphasia therapy following stroke. We outline the processes and outcomes of treatment fidelity monitoring in a pre-specified secondary analysis of the VERSE trial. METHODS: VERSE was a 3-arm, single-blinded RCT with a 12-week primary endpoint comparing Usual Care (UC) to two higher intensity treatments: Usual Care-Plus (UC-Plus) and VERSE, a prescribed intervention. Primary outcome results were previously reported. This secondary analysis focused on treatment fidelity. Video-recorded treatment sessions in the higher intensity study arms were evaluated for treatment adherence and treatment differentiation. Treatment components were evaluated using a pre-determined fidelity checklist. PRIMARY OUTCOME: prescribed amount of therapy time (minutes); secondary outcomes: (i) adherence to therapy protocol (%) and (ii) treatment differentiation between control and high intensity groups. RESULTS: Two hundred forty-six participants were randomised to Usual Care (n=81), Usual Care-Plus (n=82), and VERSE (n=83). One hundred thirty-five (82%) participants in higher intensity intervention arms received the minimum prescribed therapy minutes. From 10,805 (UC 7787; UC-Plus 1450; VERSE 1568) service events, 431 treatment protocol deviations were noted in 114 participants. Four hundred thirty-seven videos were evaluated. The VERSE therapists achieved over 84% adherence to key protocol elements. Higher stroke and aphasia severity, older age, and being in the UC-Plus group predicted more treatment deviations. CONCLUSIONS: We found high levels of treatment adherence and differentiation between the intervention arms, providing greater confidence interpreting our results. The comprehensive systems for intervention fidelity monitoring and reporting in this trial make an important contribution to aphasia research and, we argue, should set a new standard for future aphasia studies. TRIAL REGISTRATION: ACTRN 12613000776707.

Statistical analysis plan for the stepped wedge clinical trial Healing Right Way-enhancing rehabilitation services for Aboriginal Australians after brain injury.

BACKGROUND: Aboriginal Australians are known to suffer high levels of acquired brain injury (stroke and traumatic brain injury) yet experience significant barriers in accessing rehabilitation services. The aim of the Healing Right Way trial is to evaluate a culturally secure intervention for Aboriginal people with newly acquired brain injury to improve their rehabilitation experience and quality of life. Following publication of the trial protocol, this paper outlines the statistical analysis plan prior to locking the database.  METHODS: The trial involves a stepped wedge design with four steps over 3 years. Participants were 108 adult Aboriginal Australians admitted to one of eight hospitals (four rural, four urban) in Western Australia within 6 weeks of onset of a new stroke or traumatic brain injury who consented to follow-up for 26 weeks. All hospital sites started in a control phase, with the intervention assigned to pairs of sites (one metropolitan, one rural) every 26 weeks until all sites received the intervention. The two-component intervention involves training in culturally safe care for hospital sites and enhanced support provided to participants by Aboriginal Brain Injury Coordinators during their hospital stay and after discharge. The primary outcome is quality of life as measured by the Euro QOL-5D-3L VAS. A mixed effects linear regression model will be used to assess the between-group difference at 26 weeks post-injury. The model will control for injury type and severity, age at recruitment and time since commencement of the trial, as fixed effects. Recruitment site and participant will be included as random effects. Secondary outcomes include measurements of function, independence, anxiety and depression, carer strain, allied health occasions of service received and hospital compliance with minimum processes of care based on clinical guidelines and best practice models of care. DISCUSSION: The trial will provide the first data surrounding the effectiveness of an intervention package for Aboriginal people with brain injury and inform future planning of rehabilitation services for this population. The statistical analysis plan outlines the analyses to be undertaken. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12618000139279. Registered 30 January, 2018.

Hospital staff, volunteers' and patients' perceptions of barriers and facilitators to communication following stroke in an acute and a rehabilitation private hospital ward: a qualitative description study.

OBJECTIVES: To explore barriers and facilitators to patient communication in an acute and rehabilitation ward setting from the perspectives of hospital staff, volunteers and patients following stroke. DESIGN: A qualitative descriptive study as part of a larger study which aimed to develop and test a Communication Enhanced Environment model in an acute and a rehabilitation ward. SETTING: A metropolitan Australian private hospital. PARTICIPANTS: Focus groups with acute and rehabilitation doctors, nurses, allied health staff and volunteers (n=51), and interviews with patients following stroke (n=7), including three with aphasia, were conducted. RESULTS: The key themes related to barriers and facilitators to communication, contained subcategories related to hospital, staff and patient factors. Hospital-related barriers to communication were private rooms, mixed wards, the physical hospital environment, hospital policies, the power imbalance between staff and patients, and task-specific communication. Staff-related barriers to communication were staff perception of time pressures, underutilisation of available resources, staff individual factors such as personality, role perception and lack of knowledge and skills regarding communication strategies. The patient-related barrier to communication involved patients' functional and medical status. Hospital-related facilitators to communication were shared rooms/co-location of patients, visitors and volunteers. Staff-related facilitators to communication were utilisation of resources, speech pathology support, staff knowledge and utilisation of communication strategies, and individual staff factors such as personality. No patient-related facilitators to communication were reported by staff, volunteers or patients. CONCLUSIONS: Barriers and facilitators to communication appeared to interconnect with potential to influence one another. This suggests communication access may vary between patients within the same setting. Practical changes may promote communication opportunities for patients in hospital early after stroke such as access to areas for patient co-location as well as areas for privacy, encouraging visitors, enhancing patient autonomy, and providing communication-trained health staff and volunteers.

The development of aboriginal brain injury coordinator positions: a culturally secure rehabilitation service initiative as part of a clinical trial.

Brain injury, resulting from stroke and traumatic brain injury, is a common occurrence in Australia, with Aboriginal people affected at a significant rate and impact felt by individuals, families and communities. Access to brain injury rehabilitation services for Aboriginal people is reported to be often limited, with very little support outside the hospital environment. Our research involving Aboriginal brain injury survivors and their families to date has revealed that people often manage 'on their own' following such events. Following recommendations from survivors and their families, the Healing Right Way clinical trial, currently underway in Western Australia, has created the role of Aboriginal Brain Injury Coordinator (ABIC) to assist in navigating information and services, particularly after discharge from hospital. Eight positions for this role have been instigated across metropolitan and rural regions in the state. Healing Right Way's aim is to enhance rehabilitation services and improve quality of life for Aboriginal Australians after brain injury. The ABIC's role is to provide education, support, liaison and advocacy services to participants and their families over a six-month period, commencing soon after the participant's stroke or injury has occurred. This paper outlines the development of this role, the partnerships involved, experiences to date and identifies some facilitators and barriers encountered that may impact the role's ongoing sustainability. Details of components of the planned full Process Evaluation of Healing Right Way related to the ABIC role and the partnerships surrounding it are also provided. In combination with the trial's ultimate results, this detail will assist in future service planning and provide a model of culturally secure care for stroke and brain injury services that can also inform other sub-acute and primary care models.

A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study.

BACKGROUND: Effectiveness of early intensive aphasia rehabilitation after stroke is unknown. The Very Early Rehabilitation for SpEech trial (VERSE) aimed to determine whether intensive aphasia therapy, beginning within 14 days after stroke, improved communication recovery compared to usual care. METHODS: Prospective, randomized, single-blinded trial conducted at 17 acute-care hospitals across Australia/New Zealand from 2014 to 2018. Participants with aphasia following acute stroke were randomized to receive usual care (direct usual care aphasia therapy), or one of two higher intensity regimens (20 sessions of either non-prescribed (usual care-plus or prescribed (VERSE) direct aphasia therapy). The primary outcome was improvement of communication on the Western Aphasia Battery-Revised Aphasia Quotient (AQ) at 12 weeks after stroke. Our pre-planned intention to treat analysis combined high intensity groups for the primary outcome. FINDINGS: Among 13,654 acute stroke patients screened, 25% (3477) had aphasia, of whom 25% (866) were eligible and 246 randomized to usual care (n = 81; 33%), usual care-plus (n = 82; 33%) or VERSE (n = 83; 34%). At 12 weeks after stroke, the primary outcome was assessed in 217 participants (88%); 14 had died, 9 had withdrawn, and 6 were too unwell for assessment. Communication recovery was 50.3% (95% CI 45.7-54.8) in the high intensity group (n = 147) and 52.1% (95% CI 46.1-58.1) in the usual care group (n = 70; difference -1.8, 95% CI -8.7-5.0). There was no difference between groups in non-fatal or fatal adverse events (p = 0.72). INTERPRETATION: Early, intensive aphasia therapy did not improve communication recovery within 12 weeks post stroke compared to usual care.