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.

Can a writing intervention using mainstream Assistive Technology software compensate for dysgraphia and support reading comprehension for people with aphasia?

BACKGROUND: Stroke profoundly affects quality of life (QOL), including loss of employment, reduced social activity, shrinking social networks and low mood. Dysgraphia (impaired writing) is a common symptom of aphasia yet is rarely targeted in rehabilitation. Recent technological advances might challenge this, since much communication is now conducted digitally through writing. The rehabilitation of writing may therefore help to address the wider consequences of stroke and aphasia. AIMS: Can assistive technology (AT) training for people with dysgraphia: (1) improve written output, and are gains achieved only with AT? (2) improve reading comprehension scores, and are gains achieved only with AT? and (3) affect social participation, mood or QOL METHODS AND PROCEDURES: DESIGN: A mixed-methods, repeated measures, small group study design was adopted (qualitative outcomes will be reported elsewhere). PARTICIPANTS: Recruited from community settings, for example, Stroke Association communication support groups. INCLUSION CRITERIA: over 18 years old, aphasia due to stroke, acquired dysgraphia, writing more impaired than speech, fluent English prior to stroke, access to computer and Internet. EXCLUSION CRITERIA: currently receiving speech and language therapy, significant cognitive impairment, neuromuscular/motor-speech impairments/structural abnormalities, developmental dyslexia, uncorrected visual/auditory impairments. PROCEDURES: Screening and diagnostic assessments at time T1 (first baseline). Outcome measures at T1; repeated at T2 (second baseline), T3 (end of intervention), T4 (3-month follow up). Social participation assessment and cognitive monitoring at T2, T3, T4. INTERVENTION: Seven-ten hours individual therapy weekly and additional email support. Participants were trained to operate Dragon NaturallySpeaking (speech to text package) and ClaroRead (read writing aloud). Outcome measures were administered on pen and paper (control) and on computer, with AT enabled only at T3, T4. OUTCOMES AND RESULTS: Computer narrative writing was significantly improved by AT training (Friedman's χ2 (3) = 8.27, p = 0.041), indicating a compensatory effect of AT. Though reading comprehension significantly improved in the computer condition (Friedman's χ2 (3) = 21.07, p = 0.001), gains could not be attributed to the AT. Gains were achieved only when measures were administered on the keyboard, with AT enabled. Thus, a compensatory rather than remediatory effect was suggested. Social network size significantly increased; there were no significant changes in mood/QOL. Individual success rates varied. CONCLUSION AND IMPLICATIONS: The customisable AT training was acceptable to participants and resulted in significantly improved narrative writing. Compensatory AT interventions are a useful adjunct to remediatory writing interventions and may particularly support functional writing. WHAT THIS PAPER ADDS: What is already known on this subject Writing is rarely spared in aphasia and may present as the most impaired communication modality. Yet, people with aphasia report that writing is seldom included in their rehabilitation. Many communication activities are now conducted digitally through writing, therefore rehabilitation of this is more important than ever before. This study sought to address whether an assistive technology (AT) software package can improve writing and whether any changes were compensatory or remediatory. What this study adds to existing knowledge This group study found that AT training led to gains in written discourse and social network in people with aphasia and dysgraphia. Gains were not replicated in handwritten tasks, suggesting this was a compensatory therapeutic approach. What are the clinical implications of this work? AT programs such as this may present speech and language therapists with a practical, pragmatic adjunct to writing or typing therapy, particularly for clients with chronic, intractable impairments for whom remediatory therapy may have a low chance of success.

Measuring communication as a core outcome in aphasia trials: Results of the ROMA-2 international core outcome set development meeting.

BACKGROUND: Evidence-based recommendations for a core outcome set (COS; minimum set of outcomes) for aphasia treatment research have been developed (the Research Outcome Measurement in Aphasia-ROMA, COS). Five recommended core outcome constructs: communication, language, quality of life, emotional well-being and patient-reported satisfaction/impact of treatment, were identified through three international consensus studies. Constructs were paired with outcome measurement instruments (OMIs) during an international consensus meeting (ROMA-1). Before the current study (ROMA-2), agreement had not been reached on OMIs for the constructs of communication or patient-reported satisfaction/impact of treatment. AIM: To establish consensus on a communication OMI for inclusion in the ROMA COS. METHODS & PROCEDURES: Research methods were based on recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) Initiative. Participants with expertise in design and conduct of aphasia trials, measurement instrument development/testing and/or communication outcome measurement were recruited through an open call. Before the consensus meeting, participants agreed on a definition of communication, identified appropriate OMIs, extracted their measurement properties and established criteria for their quality assessment. During the consensus meeting they short-listed OMIs and participants without conflicts of interest voted on the two most highly ranked instruments. Consensus was defined a priori as agreement by ≥ 70% of participants. OUTCOMES & RESULTS: In total, 40 researchers from nine countries participated in ROMA-2 (including four facilitators and three-panel members who participated in pre-meeting activities only). A total of 20 OMIs were identified and evaluated. Eight short-listed communication measures were further evaluated for their measurement properties and ranked. Participants in the consensus meeting (n = 33) who did not have conflicts of interest (n = 29) voted on the top two ranked OMIs: The Scenario Test (TST) and the Communication Activities of Daily Living-3 (CADL-3). TST received 72% (n = 21) of 'yes' votes and the CADL-3 received 28% (n = 8) of 'yes' votes. CONCLUSIONS & IMPLICATIONS: Consensus was achieved that TST was the preferred communication OMI for inclusion in the ROMA COS. It is currently available in the original Dutch version and has been adapted into English, German and Greek. Further consideration must be given to the best way to measure communication in people with mild aphasia. Development of a patient-reported measure for satisfaction with/impact of treatment and multilingual versions of all OMIs of the COS is still required. Implementation of the ROMA COS would improve research outcome measurement and the quality, relevance, transparency, replicability and efficiency of aphasia treatment research. WHAT THIS PAPER ADDS: What is already known on this subject International consensus has been reached on five core constructs to be routinely measured in aphasia treatment studies. International consensus has also been established for OMIs for the three constructs of language, quality of life and emotional well-being. Before this study, OMIs for the constructs of communication and patient-reported satisfaction/impact of treatment were not established. What this paper adds to existing knowledge We gained international consensus on an OMI for the construct of communication. TST is recommended for inclusion in the ROMA COS for routine use in aphasia treatment research. What are the potential or actual clinical implications of this work? The ROMA COS recommends OMIs for a minimum set of outcomes for adults with post-stroke aphasia within phases I-IV aphasia treatment research. Although not intended for clinical use, clinicians may employ the instruments of the ROMA COS, considering the quality of their measurement properties. The systematic inclusion of a measure of communication, such as TST, in clinical practice could ultimately support the implementation of research evidence and best practices.

A pilot economic evaluation of a feasibility trial for SUpporting wellbeing through PEeR-Befriending (SUPERB) for post-stroke aphasia.

OBJECTIVES: To explore the feasibility of a full economic evaluation of usual care plus peer-befriending versus usual care control, and potential cost-effectiveness of peer-befriending for people with aphasia. To report initial costs, ease of instruments' completion and overall data completeness. DESIGN: Pilot economic evaluation within a feasibility randomised controlled trial. SETTING: Community, England. PARTICIPANTS: People with post-stroke aphasia and low levels of psychological distress. INTERVENTION: All participants received usual care; intervention participants received six peer-befriending visits between randomisation and four months. MAIN MEASURES: Costs were collected on the stroke-adapted Client Service Receipt Inventory (CSRI) for health, social care and personal out-of-pocket expenditure arising from care for participants and carers at 4- and 10-months post-randomisation. Health gains and costs were reported using the General Health Questionnaire-12 and the EQ-5D-5L. Mean (CI) differences for costs and health gains were reported and uncertainty represented using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS: 56 participants were randomised. Mean age was 70.1 (SD 13.4). Most (n = 37, 66%) had mild and many (n = 14; 25%) severe aphasia. There was ≥94% completion of CSRI questions. Peer-befriending was higher in intervention arm (p < 0.01) but there were no significant differences in total costs between trial arms. Peer-befriending visits costed on average £57.24 (including training and supervision costs). The probability of peer-befriending being cost-effective ranged 39% to 66%. CONCLUSIONS: Economic data can be collected from participants with post-stroke aphasia, indicating a full economic evaluation within a definitive trial is feasible. A larger study is needed to demonstrate further cost-effectiveness of peer-befriending.

Supporting wellbeing through peer-befriending (SUPERB) for people with aphasia: A feasibility randomised controlled trial.

OBJECTIVE: To determine the feasibility and acceptability of peer-befriending, for people with aphasia. DESIGN: Single-blind, parallel-group feasibility randomised controlled trial comparing usual care to usual care + peer-befriending. PARTICIPANTS AND SETTING: People with aphasia post-stroke and low levels of distress, recruited from 5 NHS Hospitals and linked community services; their significant others; and 10 befrienders recruited from community. INTERVENTION: Six 1-hour peer-befriending visits over three months. MAIN MEASURES: Feasibility parameters included proportion eligible of those screened; proportion consented; missing data; consent and attrition rates. Acceptability was explored through qualitative interviews. Outcomes for participants and significant others were measured at baseline, 4- and 10-months; for peer-befrienders before training and after one/two cycles of befriending. RESULTS: Of 738 patients identified, 75 were eligible of 89 fully screened (84%), 62 consented (83% of eligible) and 56 randomised. Attrition was 16%. Adherence was high (93% attended ⩾2 sessions, 81% all six). The difference at 10 months on the GHQ-12 was 1.23 points on average lower/better in the intervention arm (95% CI 0.17, -2.63). There was an 88% decrease in the odds of GHQ-12 caseness (95% CI 0.01, 1.01). Fourty-eight significant others and 10 peer-befrienders took part. Procedures and outcome measures were acceptable. Serious adverse events were few (n = 10, none for significant others and peer-befrienders) and unrelated. CONCLUSIONS: SUPERB peer-befriending for people with aphasia post-stroke experiencing low levels of distress was feasible. There was preliminary evidence of benefit in terms of depression. Peer-befriending is a suitable intervention to explore further in a definitive trial.Clinical trial registration-URL: http://www.clinicaltrials.gov Unique identifier: NCT02947776Subject terms: Translational research, mental health, rehabilitation, quality and outcomes, stroke.

Treatment fidelity of technology-enhanced reading therapy (CommuniCATE) for people with aphasia.

BACKGROUND: Treatment fidelity (TF), that is, the degree to which the treatment delivery has adhered to protocol, is an important aspect of establishing treatment validity and reliability. Research has shown that establishing TF is only done in a small percentage of aphasia treatment studies. AIMS: This project supports the work of the CommuniCATE study, which explored the benefits of technology-enhanced aphasia therapy on participants' reading, writing, speech and conversation skills. It examines the TF of the Reading strand of the CommuniCATE project by assessing whether the therapy adhered to the protocol. The following research questions were asked: Does treatment delivery adhere to treatment protocol? Does the degree of TF vary according to the person delivering the therapy (i.e. student therapist or qualified therapist)? Does the degree of TF vary over time (early treatment sessions compared with later treatment sessions)? Was the checklist tool reliable? METHODS & PROCEDURES: This study assessed the fidelity of 38 retrospective video recordings of therapy. It used a checklist measure of criteria to which the delivery of the sessions should adhere, and against which the sessions were rated. Participants were the people with aphasia receiving therapy, the students and qualified speech and language therapists delivering therapy, and the independent raters assessing the sessions. A sample of sessions was randomly chosen, including sessions delivered by qualified therapists and by students, and sessions from different time points in the treatment process. The fidelity was rated by the first author, and the fidelity rating calculated as a percentage. Comparisons in fidelity scores for the different variables were drawn using Mann-Whitney tests. The reliability of the checklist was assessed through inter and intra-rater reliability testing, and the results were analysed using Kappa statistics. OUTCOMES & RESULTS: High fidelity was found across all therapy conditions with a mean score of 98.2%. Fidelity scores were not affected by the administrator of therapy; sessions delivered by qualified and student therapists were rated equally highly. There was a small but significant effect of time, with later treatment sessions scoring more highly than earlier sessions. However, scores across both periods > 90%. Inter-rater reliability found a high percentage agreement of 93.3% and a Poor Kappa agreement level. Intra-rater agreement found a high percentage agreement of 97.3% and a Fair Kappa agreement level. CONCLUSIONS & IMPLICATIONS: The CommuniCATE reading therapy was implemented as per the protocol across time points, and withstood delegation to students. The high fidelity and good reliability scores have positive implications for the study's validity and reliability, and for the study's replication. WHAT THIS PAPER ADDS: What is already known on the subject TF refers to the degree to which the delivery of core components of a treatment matches the implementation guidelines, that is, the adherence to protocol. Despite the acknowledged importance of TF reporting, this is often neglected in the literature. What this paper adds to existing knowledge This paper shows that the TF assessment of the CommuniCATE study (reading strand) found a 98.2% fidelity score, and that high fidelity was not compromised across treatment conditions. This paper outlines the principles of TF and highlights the need for measures to be in place to establish TF, for example, manuals, training and supervision; and to monitor TF, for example, via the use of checklists. This paper also underlines the scarcity of TF measures and checks in aphasia research. This paper therefore serves as a model of TF practice in aphasia therapy research. What are the potential or actual clinical implications of this work? This study contributes to the findings of the CommuniCATE project (reading strand), and the high fidelity findings enhance the validity of the project and indicate that the therapy manual and training enable accurate implementation of delivery. This paper also contributes to the literature on TF evaluation in aphasia studies, which is presently lacking, and highlights the need for increased focus on the optimum strategies of TF reporting.

'Emotion is of the essence. Number one priority': A nested qualitative study exploring psychosocial adjustment to stroke and aphasia.

BACKGROUND: Stroke and aphasia can have a profound impact on people's lives, and depression is a common, frequently persistent consequence. Social networks also suffer, with poor social support associated with worse recovery. It is essential to support psychosocial well-being post-stroke, and examine which factors facilitate successful adjustment to living with aphasia. AIMS: In the context of a feasibility randomized controlled trial of peer-befriending (SUPERB), this qualitative study explores adjustment for people with aphasia in the post-acute phase of recovery, a phase often neglected in previous research. METHODS & PROCEDURES: Semi-structured interviews were conducted with 20 people with aphasia and 10 significant others, who were purposively sampled from the wider group of 56 people with aphasia and 48 significant others. Interviews took place in participants' homes; they were analysed using framework analysis. OUTCOMES & RESULTS: Participants with aphasia were 10 women and 10 men; their median (interquartile range-IQR) age was 70 (57.5-77.0) years. Twelve participants had mild aphasia, eight moderate-severe aphasia. Significant others were six women and four men with a median (IQR) age of 70.5 (43-79) years. They identified a range of factors that influenced adjustment to aphasia post-stroke. Some were personal resources, including mood and emotions; identity/sense of self; attitude and outlook; faith and spirituality; and moving forward. Significant others also talked about the impact of becoming carers. Other factors were external sources of support, including familial and other relationships; doctors, nurses and hospital communication; life on the ward; therapies and therapists; psychological support, stroke groups; and community and socializing. CONCLUSIONS & IMPLICATIONS: To promote adjustment in the acute phase, hospital staff should prioritize the humanizing aspects of care provision. In the post-acute phase, clinicians play an integral role in supporting adjustment and can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy. What this paper adds What is already known on the subject Anxiety and depression are common consequences of stroke, with depression rates high at 33% at 1 year post-onset. There is evidence that the psychological needs of people with aphasia are even greater than those of the general stroke population. Social support and social networks are also negatively impacted. Few studies have examined adjustment when people are still in hospital or in the early stages of post-stroke life in the community (< 6 months). Further, many stroke studies exclude people with aphasia. What this paper adds to existing knowledge Adjustment to living with stroke and aphasia begins in the early stages of recovery. While this partly depends on personal resources, many factors depend on external sources of help and support. These include doctors, nurses and hospital communication, their experience of life on the ward, and their therapists' person-centred care. What are the potential or actual clinical implications of this work? Clinicians play an integral role in facilitating people with aphasia to utilize their personal resources and support systems to adjust to life after stroke. They can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy.

UK speech and language therapists' views and reported practices of discourse analysis in aphasia rehabilitation.

BACKGROUND: Discourse assessment and treatment in aphasia rehabilitation is a priority focus for a range of stakeholder groups. However, a significant majority of speech and language therapists (SLTs) infrequently conduct discourse analysis, and do not feel competent in doing so. Known barriers identified in other countries, specifically a lack of time, training, expertise and resources, affect use of discourse analysis in clinical practice. AIMS: To investigate UK SLTs' reported practices and views of discourse analysis, barriers and facilitators, and clinical feasibility in aphasia rehabilitation. METHODS & PROCEDURES: An online survey of 52 questions adapted from existing research and incorporating behaviour change literature was created for the study and piloted. UK SLTs working in aphasia rehabilitation for at least 6 months were invited to participate. Potential participants were contacted through national and local clinical excellence networks, a National Health Service (NHS) bespoke e-mail list, and national magazine advertisement, and the study was also advertised on social media (Twitter). Therapists read an online participant information sheet and submitted individual electronic consent online; then progressed to the Qualtrics survey. Descriptive, correlational and inferential statistical analyses were conducted, and content analysis was carried out on the questions requiring text. OUTCOMES & RESULTS: A total of 211 valid responses were received from primarily female SLTs, aged 20-40 years, working full-time in the NHS in England, in community, inpatient and acute/subacute multidisciplinary settings. A total of 30% SLTs collected discourse analysis often, were mostly very experienced, and working part-time in community settings. Years of experience was predictive of use. Discourse was most often collected using standardized picture descriptions and recounts during initial assessment. Samples were infrequently recorded, and typically transcribed in real-time. Most SLTs (53-95%) reported making clinical judgements or manually counted words, sentences, communication of ideas and errors, and were confident in doing so. Barriers included time constraints; lack of expertise, confidence, training, resources and equipment; and patient severity. Discourse 'super-users' were distinguished by significantly higher professional motivation for discourse and workplace opportunity than other SLTs, and 'non-users' were distinguished by significantly less knowledge and skills in discourse analysis than other SLTs. SLTs reported a desire and need for training, new/assistive tools and time to do more discourse analysis in practice. CONCLUSIONS & IMPLICATIONS: Clinicians were highly engaged and relatively active in at least some aspects of discourse analysis practice. Interventions that target individual clinicians as well as organizations and systems are needed to improve the uptake of discourse analysis in practice. What this paper adds What is already known on the subject? Discourse in aphasia rehabilitation is a priority in clinical practice and research. However, the majority of clinicians infrequently collect and analyse discourse. Research in Australia and the United States indicated that lack of time, assessment resources and relevant knowledge and skills are the main barriers to use. What this paper adds to existing knowledge Compared with existing research, UK SLTs were more likely to see discourse analysis as part of their role and experienced fewer barriers, and more SLTs did it at least sometimes in clinic. However, practices were limited by lack of training, giving rise to challenges in selecting and interpreting findings for clients. More use was predicted by more experience and commitment to discourse analysis, particularly where workplaces supported this approach. Less use was associated with less knowledge and skills in discourse analysis. Practice and decision-making were influenced by client factors and constrained to a lesser degree by logistical challenges. What are the potential or actual clinical implications of this study? Education and training in discourse analyses and in specific procedures are needed to improve individual clinicians' knowledge, skills and confidence in using discourse analysis for clients' rehabilitation. Equally, organizational and systems changes are needed to promote, support and reinforce discourse analysis in the workplace.

The influence of conversation parameters on gesture production in aphasia.

Conversation is important in everyday life and this importance is not diminished in aphasia. Context parameters such as topic and partner are known to influence the linguistic content of conversations. With gesture being closely linked to language, these parameters may influence gestures used in conversations. This has not been investigated in previous studies. This study explored the spontaneous use of gestures in the conversations of participants with aphasia (PWA) and neurologically healthy participants (NHP). It aimed to examine the influence of conversation topic and partner on gesture production overall and on the production of semantically rich and empty gestures. Twenty PWA and 21 NHP were filmed during conversations with different topics (narrative & procedural) and different partners (familiar & unfamiliar). Analysis 1 investigated the influence of the conversation topic on gesture production overall and on the production of semantically rich and empty gestures. In Analysis 2, the influence of the conversation partner on gesture production was investigated. Both groups produced significantly more gestures in procedural than in narrative conversations. Moreover, PWA and NHP produced significantly more semantically rich gestures in procedural conversations. In terms of the conversation partner, both groups produced significantly more gestures in the conversations with the unfamiliar than in those with the familiar conversation partner. For all findings, there were no group differences and no interactions between group and context parameters. These findings shed light on factors that influence gesture production and suggest that both modalities should be viewed together as a communicative resource for PWA.

Feasibility and initial efficacy of project-based treatment for people with ABI.

BACKGROUND: Communication impairments are common and pervasive for people a long time following acquired brain injury (ABI). These impairments have a significant impact on a person's quality of life (QOL) post-injury. Project-based treatment is a treatment approach that could have an impact on communication skills and QOL for people with ABI a long-term post-injury. This treatment is embedded in a context of meaningful activities chosen by people with ABI, whereby, as a group, they work collaboratively to achieve a tangible end product. AIMS: To evaluate the feasibility and initial efficacy of project-based treatment on improving the communication skills and QOL for people with ABI. METHODS & PROCEDURES: An exploratory controlled trial with alternate allocation of groups, and follow-up at 6-8 weeks, was completed. Twenty-one people with chronic ABI were recruited in groups of two to three from community settings, allocated to either a TREATMENT (n = 11) or WAITLIST group (n = 10). Participants attended a 20-h group-based treatment over 6 weeks where they worked towards achieving a project that helped others. To determine feasibility, four criteria were used: demand, implementation, practicality and acceptability. A range of communication and QOL outcomes was used to determine a fifth feasibility criterion, initial efficacy. Some of these criteria were additionally used to evaluate the feasibility of the outcomes. OUTCOMES & RESULTS: All participants received the treatment as allocated with high attendance and no dropouts. The treatment was feasible to deliver as intended and was highly acceptable to participants. Medium and large effect sizes were found from pre- to post-treatment, and from pre-treatment to follow-up for measures of conversation, perceived communicative ability and QOL. CONCLUSIONS & IMPLICATIONS: Project-based treatment is feasible with indications of initial efficacy for both communication skills and QOL. The treatment provides a promising new approach for improving communication skills and QOL in people with chronic acquired brain injuries in the community setting.

Setting and achieving individualized social communication goals for people with acquired brain injury (ABI) within a group treatment.

BACKGROUND: Cognitive-communication disorders are common following an acquired brain injury (ABI). Remediation should involve individualized goal-setting, yet few reports describe the effectiveness of setting communication goals in a group setting. AIMS: To describe a process for setting and achieving goals for people with ABI. METHODS & PROCEDURES: A total of 21 participants with ABI participated in a group treatment (triads and dyads) over 6 weeks (20 h in total). Specific social communication goals were set using goal attainment scaling (GAS) with the participant and their communication partner. Goals targeted strategy use that accounted for existing cognitive abilities. The participant and their communication partner evaluated the goals post-treatment and 6-8 weeks later. Data were analysed using Friedman's test to identify the achievement of GAS goals. OUTCOMES & RESULTS: A total of 20 participants recalled goals independently post-treatment. Significant improvement post-treatment on GAS goals was rated by both the participant (p < 0.001) and their communication partner (p < 0.001). This improvement was maintained at follow-up. No significant differences in ratings were found between participants and their communication partners at either time point. CONCLUSIONS & IMPLICATIONS: Individualized social communication goals can be set and achieved for people with ABI in group treatment, even when participants are several years post-injury. GAS offers a method for structuring and quantifying goal progress. Involving communication partners and cognitive strategies were effective in improving communication.

Technology-enhanced writing therapy for people with aphasia: results of a quasi-randomized waitlist controlled study.

BACKGROUND: Acquired writing impairment, or dysgraphia, is common in aphasia. It affects both handwriting and typing, and may recover less well than other aphasic symptoms. Dysgraphia is an increasing priority for intervention, particularly for those wishing to participate in online written communication. Effective dysgraphia treatment studies have been reported, but many did not target, or did not achieve, improvements in functional writing. Functional outcomes might be promoted by therapies that exploit digital technologies, such as voice recognition and word prediction software. AIMS: This study evaluated the benefits of technology-enhanced writing therapy for people with acquired dysgraphia. It aimed to explore the impact of therapy on a functional writing activity, and to examine whether treatment remediated or compensated for the writing impairment. The primary question was: Does therapy improve performance on a functional assessment of writing; and, if so, do gains occur only when writing is assisted by technology? Secondary measures examined whether therapy improved unassisted written naming, functional communication, mood and quality of life. METHODS & PROCEDURES: The study employed a quasi-randomized waitlist controlled design. A total of 21 people with dysgraphia received 12 h of writing therapy either immediately or after a 6-week delay. The primary outcome measure was a functional assessment of writing, which was administered in handwriting and on a computer with assistive technology enabled. Secondary measures were: The Boston Naming Test (written version), Communication Activities of Daily Living-2, Visual Analogue Mood Scales (Sad question), and the Assessment of Living with Aphasia. Analyses of variance (ANOVA) were used to examine change on the outcome measures over two time points, between which the immediate group had received therapy but the delayed group had not. Pre-therapy, post-therapy and follow-up scores on the measures were also examined for all participants. OUTCOMES & RESULTS: Time × group interactions in the ANOVA analyses showed that therapy improved performance on the functional writing assessment. Further interactions with condition showed that gains occurred only when writing was assisted by technology. There were no significant interactions in the analyses of the secondary outcome measures. A treatment effect on these measures was therefore unconfirmed. CONCLUSIONS & IMPLICATIONS: This study showed that 21 people with dysgraphia improved on a functional writing measure following therapy using assistive technology. The results suggest that treatment compensated for, rather than remediated, the impairment, given that unassisted writing did not change. Further studies of technology-enhanced writing therapy are warranted.

A comparison of remote therapy, face to face therapy and an attention control intervention for people with aphasia: a quasi-randomised controlled feasibility study.

OBJECTIVE: To test the feasibility of a randomised controlled trial comparing face to face and remotely delivered word finding therapy for people with aphasia. DESIGN: A quasi-randomised controlled feasibility study comparing remote therapy delivered from a University lab, remote therapy delivered from a clinical site, face to face therapy and an attention control condition. SETTING: A University lab and NHS outpatient service. PARTICIPANTS: Twenty-one people with aphasia following left hemisphere stroke. INTERVENTIONS: Eight sessions of word finding therapy, delivered either face to face or remotely, were compared to an attention control condition comprising eight sessions of remotely delivered supported conversation. The remote conditions used mainstream video conferencing technology. OUTCOME MEASURES: Feasibility was assessed by recruitment and attrition rates, participant observations and interviews, and treatment fidelity checking. Effects of therapy on word retrieval were assessed by tests of picture naming and naming in conversation. RESULTS: Twenty-one participants were recruited over 17 months, with one lost at baseline. Compliance and satisfaction with the intervention was good. Treatment fidelity was high for both remote and face to face delivery (1251/1421 therapist behaviours were compliant with the protocol). Participants who received therapy improved on picture naming significantly more than controls (mean numerical gains: 20.2 (remote from University); 41 (remote from clinical site); 30.8 (face to face); 5.8 (attention control); P <.001). There were no significant differences between groups in the assessment of conversation. CONCLUSIONS: Word finding therapy can be delivered via mainstream internet video conferencing. Therapy improved picture naming, but not naming in conversation.

Sleep related beliefs and their association with alcohol relapse following residential alcohol detoxification treatment.

BACKGROUND: Alcohol dependence is known to impact upon sleep, and poor sleep has been shown to affect relapse rates following treatment for alcohol dependence. AIMS: The aim of this study was to investigate the association between sleep problems and relapse in dependent drinkers in an inpatient setting. This was done by studying sleep related cognitions in individuals undergoing medically assisted alcohol withdrawal. METHOD: Sleep and sleep-related cognitions data were collected for 71 individuals undergoing detoxification treatment. Sleep was measured using sleep diaries and actigraph motion monitors. Participants completed sleep-related cognition questionnaires and were subject to telephone follow-up interviews. The results were then used to predict relapse rates 4 weeks after discharge. RESULTS: Longer sleep onset latency recorded on the unit predicted relapse at 4 weeks. Higher dysfunctional beliefs about sleep were found to be associated with lower relapse rates. CONCLUSIONS: This study suggests that some dysfunctional beliefs about sleep may support recovery following discharge from treatment. The study further supports the need for tailored cognitive-behavioural treatments for sleep difficulties in this population to reduce relapse rates.

A feasibility randomised waitlist-controlled trial of a personalised multi-level language treatment for people with aphasia: The remote LUNA study.

BACKGROUND: Stroke survivors with aphasia want to improve their everyday talking (discourse). In current UK practice, 90% of speech and language therapists believe discourse assessment and treatment is part of their role but are hampered by barriers in resources, time and expertise. There is a clinical need for well-articulated discourse assessment and treatments. LUNA is a multi-level treatment targeting words, sentences and discourse macrostructure in personal stories that addresses this clinical need. OBJECTIVES: This study aimed to assess the feasibility and acceptability of LUNA trial procedures in a randomised waitlist-controlled trial; and to evaluate preliminary efficacy. METHODS: This paper reports a phase II, waitlist-controlled, proof-of-concept feasibility trial. Participants with chronic aphasia (n = 28) were recruited from the community and randomised to an Immediate (n = 14) or Delayed (n = 14) group. LUNA treatment was delivered twice weekly for 10 weeks via the videoconferencing technology, Zoom. Feasibility was assessed in terms of participant recruitment and retention, adherence, missing data, and treatment fidelity. Preliminary treatment efficacy was assessed in terms of between group differences in outcome measures relating to discourse, language, and psychosocial state. RESULTS: The remote LUNA trial was feasible: 85% of those eligible consented to the trial; trial retention was 86%; 87% of treatment sessions were delivered as scheduled, and 79% of participants completed 80%+ of the treatment programme; data was missing only for participants who withdrew; treatment fidelity was high at 92% adherence; and only one clinical outcome measure demonstrated ceiling effects. ANCOVA analysis of the clinical outcome measures revealed group differences with medium and large effect sizes, indicating, improvements in the production of words, sentences, discourse macrostructure, overall language functioning (WAB-R), and psychosocial state (VAMS) following LUNA treatment. For most outcomes measured, similar treatment benefits were suggested in a secondary, non-parametric analysis. CONCLUSIONS: Large-scale evaluation of the clinical efficacy and cost-effectiveness of LUNA is warranted and supported by these findings. TRIAL REGISTRATION: Clinical trials registration: NCT05847023 (clinical trials.gov).

A systematic review of Intensive Comprehensive Aphasia Programmes - who takes part, what is measured, what are the outcomes?

PURPOSE: This study synthesizes participant and outcome data from peer-reviewed Intensive Comprehensive Aphasia Programme (ICAP) studies. METHODS: A systematic review was conducted following PRISMA guidelines. Study eligibility criteria were specified in relation to population, intervention, comparison, outcome, and design considerations. Data were extracted according to six research questions. Narrative synthesis was used. RESULTS: Twenty-one studies were included covering 13 ICAPs (N = 485, aged 18-86 years, between 11 and 335 months post-stroke). Twenty-seven participant selection criteria were identified. Fifty-six outcome measures spanning the WHO-ICF were used, with the majority assessing the body function domain. Only eight studies employed an experimental design with data appropriate for analysis and synthesis. Risk of bias was noted across this sub-group. Participants improved in word-finding, communication, activity/participation, and communication-related quality of life, and maintained their gains; however, except for word finding, evidence of effect came from isolated studies. Factors influencing outcomes were rarely considered. Some drop-outs, missed sessions, and fatigue were noted. Some studies reported IPD alongside group analyses. CONCLUSIONS: ICAP selection criteria need justification and should contribute to the understanding of candidacy for this treatment model. Rationalisation of ICAP treatment content and outcome measurement is required, spanning all WHO-ICF domains. Employment of the core outcome set for aphasia would enable data synthesis and facilitate comparisons between the ICAP and other therapy models.

Healthcare professionals can use this review to appreciate that the evidence base for intensive and comprehensive aphasia programmes is emerging and based on studies of varying methodological quality and thus findings are not conclusive.Patients across the lifespan and across a range of aphasia severities, and patients who are independent or have support for activities of daily living, can participate in intensive and comprehensive aphasia programmes.Patients can expect improved word finding ability from participation in an intensive and comprehensive aphasia programme, and some patients can experience benefits in functional communication, communication confidence, and aphasia-related quality of life.Outcome measurement from intensive and comprehensive aphasia programmes should encompass language functioning, communication activities/participation, quality of life, and outcomes for family members, and ideally environmental and personal factors should be considered.

The use of virtual reality in the rehabilitation of aphasia: a systematic review.

PURPOSE: This systematic review explored how virtual reality (VR) has been used to rehabilitate aphasia. MATERIALS AND METHODS: Empirical studies were included where VR was used to target language, well-being, or quality of life in adults with acquired language impairment. Degenerative communication disabilities were excluded. Seven health databases were searched in October 2021. Risk of Bias was assessed using published checklists and completeness of intervention reporting evaluated. Narrative synthesis described forms of VR, rationales given, outcome measures, communication functions targeted, characteristics of interventions, and outcomes achieved within the framework of impairment, activity, and participation. RESULTS: Fourteen studies, involving 229 participants, met the criteria. The studies employed four forms of VR with various rationales given. Interventions used published and novel protocols. Primary outcomes targeted language impairment (12/14), activity (1/14), and well-being (1/14) and achieved positive outcomes in impairment and activity. All studies were exploratory. Risk of bias was high. Findings are discussed in the context of gains achieved by VR in other health contexts and the multi-user gaming literature. CONCLUSIONS: Uses of VR in aphasia rehabilitation described in the literature are limited. Most applications target the remediation of language impairments. Opportunities to address activity, participation, and wider aspects of well-being are rare.IMPLICATIONS FOR REHABILITATIONResearch documenting the use of virtual reality (VR) to rehabilitate aphasia is limited and exploratory, so does not yet offer clear guidance for clinicians.Many of the identified studies have used known published protocols (e.g., naming therapy or scripts therapy) delivered through the novel VR format and focus on language impairment outcomes.VR offers clinicians a unique opportunity to address communication activity and participation through the use of multi-user virtual worlds, but this has only been explored by only two research teams.

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).

Delivering group support for people with aphasia in a virtual world: experiences of service providers.

PURPOSE: This study explored the acceptability to service providers of delivering a novel group support intervention for people with aphasia (PWA) in a virtual world. MATERIALS AND METHODS: The service providers were six group coordinators and 10 volunteers. Fourteen of the service providers participated in a semi-structured qualitative interview and 15 took part in a consensus group discussion. Qualitative interviews were analysed using framework analysis. For consensus group discussions, nominal group rankings were analysed and semantically similar responses were identified. RESULTS: Service providers described the virtual world as a safe space in which to communicate, connect, and experiment. The key barriers were technical, particularly relating to sound and connectivity issues. Service providers suggested a range of improvements to the virtual world and intervention programme. They reported that PWA benefitted from accessing a support group in a virtual world, with opportunities to connect socially and to develop their communication skills. CONCLUSIONS: Service providers found delivery of group support intervention in a virtual world to be acceptable. The use of a bespoke virtual world to deliver group support intervention may enhance the experience and increase its accessibility, enabling more PWA to benefit from this type of intervention.Implications for rehabilitationPeople with aphasia benefit from group support intervention but may find it difficult to access face-to-face groups.Delivery of group support intervention in a virtual world is acceptable to service providers, can enhance the experience and increase accessibility of groups.Technical challenges present potential barriers when delivering group support in a virtual world, relating particularly to sound and connectivity.Potential benefits of this model of delivery, as perceived by service providers, include opportunities to connect socially and to develop communication skills plus specific and strong levels of enjoyment of the virtual context.

Therapy for naming difficulties in bilingual aphasia: which language benefits?

BACKGROUND: The majority of the world's population is bilingual. Yet, therapy studies involving bilingual people with aphasia are rare and have produced conflicting results. One recent study suggested that therapy can assist word retrieval in bilingual aphasia, with effects generalizing to related words in the untreated language. However, this cross-linguistic generalisation only occurred into the person's stronger language (L1). While indicative, these findings were derived from just three participants, and only one received therapy in both languages. AIMS: This study addressed the following questions. Do bilingual people with aphasia respond to naming therapy techniques developed for the monolingual population? Do languages respond differently to therapy and, if so, are gains influenced by language dominance? Does cross-linguistic generalisation occur and does this depend on the therapy approach? Is cross-linguistic generalisation more likely following treatment in L2 or L1? METHODS & PROCEDURES: The study involved five aphasic participants who were bilingual in English and Bengali. Testing showed that their severity and dominance patterns varied, so the study adopted a case series rather than a group design. Each person received two phases of naming therapy, one in Bengali and one in English. Each phase treated two groups of words with semantic and phonological tasks, respectively. The effects of therapy were measured with a picture-naming task involving both treated and untreated (control) items. This was administered in both languages on four occasions: two pre-therapy, one immediately post-therapy and one 4 weeks after therapy had ceased. Testing and therapy in Bengali was administered by bilingual co-workers. OUTCOMES & RESULTS: Four of the five participants made significant gains from at least one episode of therapy. Benefits arose in both languages and from both semantic and phonological tasks. There were three instances of cross-linguistic generalisation, which occurred when items had been treated in the person's dominant language using semantic tasks. CONCLUSIONS & IMPLICATIONS: This study suggests that 'typical' naming treatments can be effective for some bilingual people with aphasia, with both L1 and L2 benefiting. It offers evidence of cross-linguistic generalisation, and suggests that this is most likely to arise from semantic therapy approaches. In contrast to some results in the academic literature, the direction of generalisation was from LI to L2. The theoretical implications of these findings are considered. Finally, the results support the use of bilingual co-workers in therapy delivery.