Engaging multiple stakeholders to improve speech and language therapy services in schools: an appreciative inquiry-based study.

BACKGROUND: Effective collaboration between speech and language therapists (SLTs) and teachers is essential in meeting the needs of children with developmental language disorders in school, but it is difficult to achieve. Currently, many children receive inadequate speech and language therapy services and/or support in school. The aim of this study was to engage key stakeholders (SLTs, teachers, parents and children with DLD) in the co-design of their ideal speech and language therapy service and support in school. The study was undertaken in order to inform the development of a conceptual model to guide collaborative practice when working with this population. METHODS: A qualitative study involving a diverse range of key stakeholders and using appreciative inquiry. This is a method which enables those involved to construct their 'ideal' about a topic of interest. Recruitment was carried out using purposive sampling. We conducted focus groups with practitioners (SLTs and teachers) and parents as well as semi-structured interviews with children who have DLD using 'draw and tell' techniques. A total of five focus groups and nine interviews were conducted with participants (n = 27). RESULTS: The children described their ideal supports as those which enabled them to connect, contribute and achieve. They describe ways in which environmental barriers in school needed to be addressed to allow them to do so. The professionals primarily described ways in which the language skills of the child could be improved. Both parents and practitioner groups described the importance of strengthening networks between service providers and service users. They also highlighted the need to promote a collaborative culture if stakeholders are to work effectively together across sectors. CONCLUSIONS: There were differences in perspectives about the ways in which speech and language therapy services and supports could be improved, demonstrating the importance of engaging a diverse group of stakeholders. Of note were the unique insights the children brought about the barriers they faced as a result of their difficulties. Based on our findings we propose that children should be given influence in decisions about the supports that they receive in school. Implications for policy, research and practice are discussed.

Speech and language therapy best practice for patients in prolonged disorders of consciousness: a modified Delphi study.

BACKGROUND: Research regarding speech and language therapy (SLT) for patients in prolonged disorders of consciousness (PDOC) is very limited. The Royal College of Physicians' (RCP) PDOC guideline provides recommendations regarding best practice, but does not give detail about many aspects of assessment and management. As a result, SLTs have little information regarding best practice for this complex patient group. AIMS: To ascertain the degree of consensus amongst expert SLTs regarding SLT best practice for patients in PDOC in order to inform the future development of SLT guidelines. METHODS & PROCEDURES: A two-round modified Delphi technique was used. Participants were recruited from major trauma centres and neurorehabilitation units in England and national SLT clinical excellence networks. To participate, SLTs had to be working on neurosciences, neurosurgery or neurorehabilitation wards that treat adult PDOC patients, or have ≥ 3 years' experience of working with PDOC. The Round 1 questionnaire was developed from the RCP's PDOC guideline and from existing research literature. It included ratings of statements regarding SLT best practice using Likert or temporal scales, with optional written justifications/comments and opportunities for participants to suggest additional statements. The percentage agreement amongst participants was calculated for each Round 1 statement. Written justifications for views were analysed using content analysis. The Round 2 questionnaire contained both quantitative and qualitative feedback from Round 1, allowing participants to reappraise their views. The final degree of consensus was then calculated after completion of both rounds. OUTCOMES & RESULTS: A total of 40 SLTs completed Round 1, with 36 completing Round 2 (90% response rate). Consensus was achieved for 87% (67/77) of statements regarding best practice on a variety of topics including communication, tracheostomy, dysphagia and oral hypersensitivity. The statements represented assessment, management and service delivery components of SLT practice. CONCLUSIONS & IMPLICATIONS: A total of 67 best practice statements were created. The statements provide a useful starting point for the creation of SLT guidelines to support best practice, and also have the potential to be used to advocate for the provision of SLT services for patients in PDOC. Future studies should focus on whether the expert opinion generated here can be borne out in experimental research.

Speech-Language Clinicians Working with Deaf Children: A Qualitative Study in Context.

Students who are deaf or hard of hearing (DHH) increasingly attend local public schools, in which speech and language clinicians (SLCs) may lack experience with the individualized needs of a heterogeneous student population. This study explored the experiences of SLCs with students who are DHH in three different types of educational settings. Fourteen SLCs were interviewed and discussed a case study. Responses were transcribed, data coded, and emergent themes identified. Analysis was verified through triangulation of data and trustworthiness strategies. Results indicated that the skill sets of SLCs working with children who were DHH were dependent on contextual factors, such as educational placement and communication mode used, and that development of these skills requires direct experience, collaboration, and structural supports. Institutions across the deaf education spectrum should consider forming alliances to improve information-sharing and collaborative learning in order to improve service delivery in all settings.

Treatment integrity of elaborated semantic feature analysis aphasia therapy delivered in individual and group settings.

BACKGROUND & AIMS: This study ran within the framework of the Thales Aphasia Project that investigated the efficacy of elaborated semantic feature analysis (ESFA). We evaluated the treatment integrity (TI) of ESFA, i.e., the degree to which therapists implemented treatment as intended by the treatment protocol, in two different formats: individual and group therapy. METHODS & PROCEDURES: Based on the ESFA manual, observation of therapy videos and TI literature, we developed two ESFA integrity checklists, for individual and group therapy, and used them to rate 15 videos of therapy sessions, delivered by three speech-language therapists (SLTs). Thirteen people with aphasia (PwA) were involved in this study. Reliability of the checklists was checked using Kappa statistics. Each session's TI was calculated. Differences in TI scores between the two therapy approaches were calculated using independent sample t-tests. Treating SLTs' views on what facilitates TI were also explored through a survey. OUTCOMES & RESULTS: Inter- and intra-rater reliability were excellent (.75 ≤ κ ≤ 1.00) for all but one video (κ = .63). Overall, a high TI level (91.4%) was achieved. Although both approaches' TI was high, TI for individual therapy sessions was significantly higher than for group sessions (94.6% and 86.7% respectively), t(13) = 2.68, p = .019. SLTs found training, use of the treatment manual, supervision and peer support useful in implementing ESFA therapy accurately. CONCLUSIONS & IMPLICATIONS: ESFA therapy as delivered in Thales is well described and therapists can implement it as intended. The high TI scores found enhance the internal validity of the main research project and facilitate its replication. The need for more emphasis on the methodological quality of TI studies is discussed.

Information behaviour of French-speaking speech-language therapists in Belgium: results of a questionnaire survey.

BACKGROUND: Speech-language therapists (SLTs) are encouraged to implement evidence-based practice (EBP). Nevertheless, EBP use by practitioners can be questioned. OBJECTIVES: The objective of this study was to explore Belgian French-speaking SLTs' information behaviour and their awareness of EBP. The collected data allow one to determine how far they have embraced this approach. METHODS: The two Belgian French-speaking SLT professional associations promoted an online questionnaire survey by email. Additionally, clinical supervisors of students were asked to participate. In March 2012, 2068 emails were sent. RESULTS: The participation rate was at least 20% (n = 415). The reported information needs mainly concerned treatment or diagnosis. Most of the time, to attempt to fulfil their information needs, SLTs relied on their own resources (personal experience and libraries) and on colleagues in the workplace. When they searched on the Internet, they preferred to use a general search engine rather than a specialised bibliographic database. Barriers to obtaining scientific information are highlighted. Only 12% of the respondents had already heard about EBP. CONCLUSION: This study provides the first overview of the information behaviour of SLTs working in the French community of Belgium. Several recommendations are suggested for SLTs and librarians.

Integrating external evidence of intervention effectiveness with both practice and the parent perspective: development of 'What Works' for speech, language, and communication needs.

AIM: The aim of the study was to develop an ecologically valid synthesis of the evidence underpinning interventions for children with speech, language, and communication needs (SLCN), integrating a range of different data sources. METHOD: Three sources of information were integrated: the Cochrane Review of interventions for children with primary speech and language delays/disorder; current practice from an online survey of 534 speech and language therapists and other professionals working with children with SLCN; and parent reports of preferred outcomes. Evidence was ranked as strong, moderate, or indicative. RESULTS: Of the 58 interventions identified, three (5%) were found to have a strong level of evidence, 32 (56%) had moderate evidence, and 23 (39%) had indicative evidence. Five were universal interventions, the remainder targeted and universal. The integrated findings were then turned into an online interactive database, which is moderated and updated at regular intervals. INTERPRETATION: There are a number of interventions that have a moderate or strong level of evidence underpinning them but they tend not to be those used by practitioners who often favour well-established familiar programmes even if they have only indicative evidence. There is a degree of complementarity between professional and parent views about outcomes, albeit with different emphases.

The performance of standardized patients in portraying clinical scenarios in speech-language therapy.

BACKGROUND: Standardized patients (SPs) are frequently included in the clinical preparation of students in the health sciences. An acknowledged benefit of using SPs is the opportunity to provide a standardized method by which students can demonstrate and develop their competency. Relatively little is known, however, about the capacity of SPs to offer an accurate and standardized performance across a speech-language therapy student cohort. AIMS: To investigate the accuracy, reproducibility (consistent performance of each SP across student interviews) and replicability (consistent performance of a number of SPs across each scenario) of SPs portraying three scenarios, each as a parent of a child presenting with a speech disorder. METHODS & PROCEDURES: Forty-four speech-language therapy students interviewed four SPs to gain a case history. All interviews were videotaped. The accuracy of SP portrayal of key features of each scenario was scored by an expert rater and two other raters. Data were analysed to determine levels of accuracy, reproducibility and replicability, and inter-rater reliability was evaluated. OUTCOMES & RESULTS: SPs were found to have moderate to high levels of accuracy across the three scenarios. There were no significant differences in the performances of each individual SP across interviews or between all SPs on each scenario, indicating that reproducibility and replicability were achieved. Overall inter-rater reliability between raters across all scenarios was greater than 80%. CONCLUSIONS & IMPLICATIONS: The results would seem to indicate that SPs can present in a standardized manner within a speech-language therapy context, confirming the value of their inclusion in clinical education programmes. Suggestions for improving the training of SPs in order to maintain accuracy are highlighted.

The reliability of methodological ratings for speechBITE using the PEDro-P scale.

BACKGROUND: speechBITE (http://www.speechbite.com) is an online database established in order to help speech and language therapists gain faster access to relevant research that can used in clinical decision-making. In addition to containing more than 3000 journal references, the database also provides methodological ratings on the PEDro-P (an adapted version of the PEDro) scale to assist clinicians in identifying the scientific quality of randomized (RCTs) and non-randomized control trials (NRCTs). While reliability of the PEDro scale has been established by similar allied health databases, the reliability of the PEDro-P scale has yet to be reported. AIMS: To examine the reliability of PEDro-P scale ratings undertaken by raters on the speechBITE database and benchmark these results to the published reliability for the original PEDro scale. Both the total score (out of ten) as well as each of the 11 scale items were included in this analysis. METHODS & PROCEDURES: speechBITE's volunteer rater network of 17 members rated the first 100 RCTs and NRCTs on the website. The criterion and overall scores for these ratings were compared with previously published reliability studies using the PEDro scale. Intra-class correlations and per cent agreement measures were used to establish and benchmark reliability. OUTCOMES & RESULTS: The speechBITE PEDro-P ratings ranged from fair to excellent for both the total score and for each of the 11 scale items. Furthermore, reliability was equal to that of other databases. CONCLUSIONS & IMPLICATIONS: speechBITE users can be confident of the reliability of ratings published on the website. Further analysis of differences between this study and previous PEDro scale reliability studies are discussed.

Social validation of vocabulary selection: ensuring stakeholder relevance.

The vocabulary needs of individuals who are unable to spell their messages continue to be of concern in the field of augmentative and alternative communication (AAC). Social validation of vocabulary selection has been suggested as one way to improve the effectiveness and relevance of service delivery in AAC. Despite increased emphasis on stakeholder accountability, social validation is not frequently used in AAC research. This paper describes an investigation of the social validity of a vocabulary set identified in earlier research. A previous study used stakeholder focus groups to identify vocabulary that could be used by South African adults who use AAC to disclose their experiences as victims of crime or abuse. Another study used this vocabulary to create communication boards for use by adults with complex communication needs. In this current project, 12 South African adults with complex communication needs who use AAC systems used a 5-point Likert scale to score the importance of each of the previously identified 57 vocabulary items. This two-step process of first using stakeholder focus groups to identify vocabulary, and then having literate persons who use AAC provide information on social validity of the vocabulary on behalf of their peers who are illiterate, appears to hold promise as a culturally relevant vocabulary selection approach for sensitive topics such as crime and abuse.

Reflections on clinical learning in novice speech-language therapy students.

BACKGROUND: Reflective practice is reported to enhance clinical reasoning and therefore to maximize client outcomes. The inclusion of targeted reflective practice in academic programmes in speech-language therapy has not been consistent, although providing opportunities for speech-language therapy students to reflect during their clinical practice has been reported. Indeed, there has been limited investigation of the nature of speech-language therapy students' reflections. AIMS: (1) To describe the breadth and depth of reflection skills of novice speech-language therapy students by utilizing structured reflective learning journals. (2) To evaluate the use of a coding system to determine its reliability and relevance in identifying reflection skills. METHODS & PROCEDURES: Participants were 52 students in their second year of a 4-year undergraduate speech-language therapy programme. Mean participant age was 20.5 years; all students were female. Participants completed guided written reflections following three interviews with a standardized patient (an actor portraying a parent of a child with delayed speech development). Reflections were coded by two raters. Nine participants' reflections were recoded by raters A and B to establish intra-rater reliability. Inter-rater reliability between these two raters was calculated and a third rater completed coding of 20% of students' reflections to further establish inter-rater reliability. OUTCOMES & RESULTS: Results indicated that the majority of students were categorized as 'reflectors'. All students demonstrated at least one element of reflection. Their reflective writing primarily focused on a discussion of the content of and strategies used within the interviews, and reflection on and for action. Results also indicated that the coding system used within the study was reliable in determining both the breadth and depth of student reflections. CONCLUSIONS & IMPLICATIONS: This study found that novice speech-language therapy students can reflect on their clinical learning experiences within a structured clinical environment involving standardized patients. Only a small number of novice students were found to be critical reflectors who were able to analyse the content of clinical interviews, view the interaction from the perspective of the patient, and record changes to their own perspective which occurred as a result. The coding system was established as reliable and thus relevant for use in furthering research on reflective practice within speech-language therapy and other disciplines. Further investigation of reflective skills within other clinical environments and with additional clinical experience is recommended.

Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession.

BACKGROUND: Speech and language therapists are encouraged to be evidence-based practitioners in contemporary clinical practice. This apparently signifies their commitment to 'good' practice. An examination of evidence-based practice (EBP) and its adoption in clinical practice is therefore warranted. AIMS: This paper aims to explore EBP, specifically research evidence, as related to the field of speech and language therapy (SLT), using profession specific and cross-disciplinary examples. It asks the reader to consider whether research evidence contributes positively to SLT practice, or adds to the demands placed on clinicians? METHODS & PROCEDURES: A review of the literature on the nature and use of research evidence in the field of speech and language therapy and related health professions was undertaken using multiple databases (Cochrane, Medline, Cinahal, BioMed, Trip, Dare) and the following up of references provided within texts and articles. This paper asks the reader to consider the topic from the perspective of the nature of research produced, the barriers perceived, and the use of research evidence by SLTs and the allied health professions. OUTCOMES & RESULTS: The uptake of research evidence in the profession is similar to other health professions and continues to be problematic. There are multiple reasons why this is so, originating from both the nature and use of research. CONCLUSIONS & IMPLICATIONS: Research evidence is one of the pillars of EBP. Despite problems with the nature and use of such evidence, it has a positive contribution to make to clinical practice as it provides for a scientific touchstone. However, it may be that the speech and language therapist and not the research evidence is the primary pivot upon which scientific practice is based.

Preparation, clinical support, and confidence of speech-language therapists managing clients with a tracheostomy in the UK.

BACKGROUND: Literature regarding the education, training, clinical support and confidence of speech-language therapists (SLTs) working with patients with a tracheostomy is limited; however, it suggests that many clinicians have reduced clinical confidence when managing this complex population, many face role and team challenges practising in this area, and most are seeking more opportunities for professional development and training. AIMS: To investigate the education, training, clinical support and confidence of SLTs in the UK who manage patients with a tracheostomy in order to identify current challenges and inform the future clinical training needs of this professional group. METHODS & PROCEDURES: Via an online survey, the clinical training, clinical support and confidence of SLTs with more than one year of clinical experience was examined. A total of 106 SLTs from the UK completed the survey. Within the questionnaire, clinicians were also asked to identify if their workplace had a tracheostomy competency training programme (CTP) to allow further exploration of the preparation, clinical support and confidence of respondents with (43% of respondents) and without (32% of respondents) a CTP. OUTCOMES & RESULTS: Most SLTs (71%) were confident managing patients with a tracheostomy. The majority were accessing professional development and receiving expert support, though many identified specific areas where more support and training was needed. Less than half the group felt up to date with the current evidence. Only 35% of clinicians felt they worked in an optimal team for tracheostomy management, and poor recognition of the role of the SLT in managing dysphagia in patients with a tracheostomy was an issue for many clinicians, particularly on more general care wards. SLTs in workplaces with a CTP were found to have received significantly more expert support, on-the-job training, access to evidence-based practice and were significantly more confident in managing ventilator-assisted patients. CONCLUSIONS & IMPLICATIONS: SLTs are eager to access further professional development and training; however, such training needs to target specific areas of need. The significant difference in the preparation, support and confidence of SLTs with CTPs in their workplace highlights potential benefits that can be achieved through workplace training and support.

Assessing the communication skills of carers working with multiple learning disabilities: a case study.

BACKGROUND: Speech and language therapists (SLTs) working with adults who have multiple learning disabilities and complex communication needs often deliver their care via indirect therapy where SLTs train carers to communicate with their clients. Yet, very little is known about how SLTs assess the carers' communication skills prior to the training even though the assessment should be the basis of this indirect therapy. AIMS: To explore the level of agreement between Finnish SLTs' assessments of carers as skilful communication partners for adults who have multiple learning disabilities and complex communication needs. To investigate which interaction strategies affect the SLTs' assessments. METHODS & PROCEDURES: Six SLTs with more than 15 years of experience in working with individuals with complex communication needs saw together ten video clips of interaction situations between a carer and an adult who had multiple learning disabilities (aged 17-50 years). The SLTs assessed the carers on a scale from one to ten. The SLTs discussed their selections before giving their final ratings. The data were analysed both quantitatively and qualitatively. The unanimity of SLTs' assessment was analysed with a test of Kendall's W. Furthermore, the frequencies of the carers' different communication acts were counted and these counts were compared with the mean of the carers' assessments. These results were further explored with the SLTs' justifications about their assessments. OUTCOMES & RESULTS: SLTs did not fully agree on which of the carers were the most skilful interaction partners. Furthermore, the six SLTs were not unanimous about which carers' interaction strategies resulted in skilful communication. However, SLTs assessed those carers higher who used facilitative verbal acts. The carers used these verbal acts to involve themselves in the interests of the client. CONCLUSIONS & IMPLICATIONS: This case study showed that Finnish SLTs seem to have different criteria about what is considered skilful communication between carers and clients who have multiple learning disabilities. Even though there might not be a single way of being a skilful interaction partner, this variable can be confusing to carers if they work with several SLTs and each of them offers different professional advice. Therefore, the results suggest a need for an assessment tool for evaluating the carers' interaction skills. In addition to this tool, it appears that SLTs also need further training to be able to perform this multifaceted task.

Cost-effectiveness of interventions for children with speech, language and communication needs (SLCN): a review using the Drummond and Jefferson (1996) 'Referee's Checklist'.

BACKGROUND: Although economic evaluation has been widely recognized as a key feature of both health services and educational research, for many years there has been a paucity of such studies relevant to services for children with speech, language and communication needs (SLCN), making the application of economic arguments to the development of services difficult. AIMS: The study has two aims, namely to review systematically the cost-effectiveness literature related to services for children with SLCN and to highlight key issues that need to be included in future economic effectiveness studies. METHODS & PROCEDURES: A comprehensive search of the international literature for the last 30 years was completed and the studies were evaluated against the 'gold standard' criteria developed by Drummond and colleagues in 1996 and 2005. OUTCOMES & RESULTS: Five studies met the review inclusion criteria. All focused on young (2-11 years) children with SLCN and most compared clinic-based and parent-administered interventions. The studies provide variable levels of detail on the key elements needed, but few provided sufficient details of costs to draw comparisons across studies. Only two studies attempted to bring together costs and effectiveness data. CONCLUSIONS & IMPLICATIONS: The studies point to the importance of home-based and indirect intervention and, in many cases, emphasize the parental perspective. There is a need for intervention studies to include a cost dimension based on readily comparable methods of establishing unit costs and for greater use to be made of cost-effectiveness analysis more generally.

Quality of life after stroke: evaluation of the Greek SAQOL-39g.

BACKGROUND/AIMS: Stroke and aphasia rehabilitation aims to improve people's quality of life. Yet, scales for measuring health-related quality of life in stroke typically exclude people with aphasia. They are also primarily available in English. An exception is the 39-item generic version of the Stroke and Aphasia Quality of Life Scale (SAQOL-39g). This scale has been tested with people with aphasia; it has been adapted for use in many countries including Greece. The aim of this study was to examine the psychometric properties of the Greek SAQOL-39g. METHODS: An interview-based psychometric study was carried out. Participants completed: receptive subtests of the Frenchay Aphasia Screening Test, the Greek SAQOL-39g, the 12-item General Health Questionnaire, the Frenchay Activities Index, the Montreal Cognitive Assessment and the Barthel Index. RESULTS: 86 people took part; 26 provided test-retest reliability data. The Greek SAQOL-39g demonstrated excellent acceptability (minimal missing data; no floor/ceiling effects), test-retest reliability [intraclass correlation coefficient = 0.96 (overall scale), 0.83-0.99 (domains)] and internal consistency [Cronbach's alpha = 0.96 (overall scale), 0.92-0.96 (domains)]. There was strong evidence for convergent [r = 0.53-0.80 (overall scale), 0.54-0.89 (domains)] and discriminant validity [r = 0.52 (overall scale), 0.04-0.48 (domains)]. CONCLUSION: The Greek SAQOL-39g is a valid and reliable scale. It is a promising measure for use in stroke and aphasia treatment prioritization, outcome measurement and service evaluation.

Current clinical practices in Aphasia Therapy in Finland: challenges in moving towards national best practice.

AIMS: The objective of this article is to discover and document the state of clinical practices for aphasia therapy in Finland and to gather information for developing national best practice. METHODS: Two surveys were administered in Finland that explored current clinical practices in aphasia rehabilitation and the resources available to speech and language therapists (SLTs). We integrated and compared the results of these surveys. The results are based on the responses of the 88 (45 + 43) returned questionnaires from SLTs. RESULTS: Four principle themes were identified: planning the aphasia therapy, measures and assessment methods, current therapy service provision, and development suggestions and barriers to change. The results of this study showed considerable consistency in clinical practices among the respondents to the surveys. However, we noticed that there are some discrepancies between the recent research findings and present clinical practices. CONCLUSIONS: The findings from this study indicate that there are many challenges in clinical decision-making at the moment in Finland. The article helps clinicians to evaluate the practices they use and to execute justified modifications in order to implement more effective models of practice. It is evident that national best practice guidelines for aphasia therapy would support SLTs in clinical decision-making.

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

BACKGROUND: Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients' quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies. METHODS: Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes. RESULTS: 4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures. CONCLUSIONS: Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Systematic review of the literature on the treatment of children with late language emergence.

BACKGROUND: Research has indicated that 24-36-month-olds with late language emergence ('late talkers') are at risk for later language-learning difficulties. Previous reviews have examined the efficacy of treatment for children with language delay/disorders; however, no systematic review has examined the effects of language treatment specifically for children with late language emergence. AIMS: This systematic review reports the effects of intervention studies conducted between 1985 and 2008 of 24-36-month-olds with late language emergence. MAIN CONTRIBUTION: Eleven studies that included a total of 275 participants were located, synthesized, and appraised for quality. Studies varied significantly with respect to methodological quality, with seven of the eleven receiving moderately strong quality scores. OUTCOMES & RESULTS: Treatment for children with late language emergence improved performance on formal measures of language, mean length of utterance, and target word use as indicated by medium to large effect sizes in these good-quality studies. Treatment descriptions and clinical implications are provided. CONCLUSIONS & IMPLICATIONS: There is evidence to suggest that focused stimulation and modelling of single words can lead to improvements in the language of children with late language emergence. Subsequent treatment studies should examine the application of these effective treatments to larger, population-based samples. Future treatment studies would also benefit from specific examination of children's receptive language level and inclusion of children with late language emergence who vary in socio-economic status and/or ethnicity.

Does it work? Why does it work? Reconciling difficult questions.

BACKGROUND: Within medicine there is an agreed hierarchy of levels of research evidence with randomized controlled trials at the top and expert opinion at the bottom. When randomized controlled trials are the final stage in testing a treatment for which there is a sound theoretical basis both the 'Does it work?' and 'How does it work?' questions may be answered. However, when the theoretical basis is underdeveloped or contentious, then randomized controlled trials will provide only partial answers and other methods or methodologies may be needed to understand more about the mechanisms involved in the treatments. AIMS: This paper aims to contribute to the debate about the nature of the evidence that is required in order to feel confident that people with communication difficulties will benefit from the treatments offered. The aim is not to discuss the relative merits of one methodology over another, but rather, by referring to one particular treatment, to show how knowledge gained from a range of research studies, using different methodologies, can be synthesized to increase one's understanding. METHODS & PROCEDURES: The initial discussion focuses on two frameworks that have been developed specifically for the evaluation of healthcare interventions. This is followed by discussion of the research evidence for the Lidcombe Program of early stuttering intervention to illustrate some issues relevant to treatment development and evaluation in the field of communication difficulty. The evidence from randomized controlled trails is related to clinicians' needs. Finally, the potential value of an iterative approach is illustrated with reference to verbal contingencies, which are an essential component of the Lidcombe Program. MAIN CONTRIBUTION: This paper considers different sorts of evidence and their contribution to one's knowledge and practice. The content provides a practical example of how knowledge and understanding of a treatment approach can develop through a synthesis of knowledge from a programme of systematic research, from research outside the field of communication difficulty, and from the process of making sense of the experiences of both clinicians and clients who use the approach. CONCLUSIONS & IMPLICATIONS: The questions 'Does it work?' and 'How does it work?' are important and require different methods of investigation. Particular treatments may be viewed as better suited to one research methodology over another, but limiting research to one fails to provide the information that practitioners need in order to justify what they do and effectively to solve problems encountered in the application of particular approaches.

National survey of speech and language therapy provision for people with Parkinson's disease in the United Kingdom: therapists' practices.

BACKGROUND: Communication and swallowing changes feature prominently in Parkinson's disease. People with Parkinson's disease appear under-represented in speech-language therapy clinics in the United Kingdom. The nature of the speech-language therapy services in the UK to people with Parkinson's disease has not been examined. AIMS: To ascertain the number of speech-language therapists in the UK who work with people with Parkinson's disease; to establish the nature of contacts in terms of caseloads, referral stages and routes, management practices, assessments and treatments employed; and to reflect on service provision in relation to published guidelines. METHODS & PROCEDURES: A questionnaire survey of speech-language therapists. OUTCOMES & RESULTS: A total of 185 speech-language therapists responded. They were treating a median of three (inter-quartile range (IQR) = 1-6) people with Parkinson's disease with a further median of five (IQR = 1-10) on review. The majority of contacts were for assessment and advice given, especially in later and earlier stages of Parkinson's disease. Typically, respondents offered a median of six sessions (IQR = 6-8) of treatment, each session lasting a median of 45 min (IQR = 45-60), delivered over a median period of 42 days (IQR = 28-56). Speech-language therapists worked in a variety of settings, predominantly hospital. They received referrals principally from medical specialities, from whom the majority had support. Referrals were perceived in general to be later in Parkinson's disease progression than desired. Assessment focused primarily on impairment measures, in contrast to a belief that therapy focus on activity and participation issues. Speech-language therapists were relatively confident in treating people with Parkinson's disease, but 75% wanted more training. CONCLUSIONS & IMPLICATIONS: Speech-language therapist services for people with Parkinson's disease in the UK are restricted on most dimensions. Management practices often do not match guideline suggestions. Consideration needs to be given to the training for, content of and delivery of speech-language therapy services for people with Parkinson's disease.