Telehealth practice in aphasia: A survey of UK speech and language therapists, with a focus on assessment.

BACKGROUND AND OBJECTIVES: Evidence suggests telehealth in speech and language therapy can enhance access to care, cost-effectiveness and satisfaction. However, little is known about use of telehealth in the United Kingdom. Moreover, many assessments/outcome measures for aphasia have been tested for face-to-face administration only, posing challenges to reliable use within the telehealth context. We explored the experiences and views of speech and language therapists (SLTs) working with people with aphasia on using telehealth to conduct assessments/outcome measures, perceived barriers and facilitators in telehealth, and their priorities for research in telehealth aphasia assessment. METHOD: We explored views of UK SLTs through an online cross-sectional survey (2021) delivered through the Qualtrics platform. The survey covered three main areas: (i) participant demographics; (ii) experience of using telehealth and doing telehealth assessments with people with aphasia post-stroke during the COVID-19 pandemic; and (iii) plans for telehealth post-pandemic. Response formats included yes/no, multiple choice, 5-point Likert scales and open-ended text responses. The survey was expected to take no more than 10 min to complete. Survey data were analysed through descriptive statistics and content analysis of open-ended questions. RESULTS: One hundred twenty-four SLTs responded to the survey. The majority (>80%) used telehealth during the COVID-19 pandemic and >90% planned to continue to use telehealth in the future. The most used platforms were Zoom, Microsoft Teams and Attend Anywhere. Access to internet and telehealth platforms, and practical problems (e.g., difficulties sharing resources online, limited functionality of telehealth platforms for assessment) were common barriers. Therapists highlighted that training, resources and materials that assist the administration of assessments were important. Most participants responded that there was a need for existing measures to be tested for administration via telehealth (n = 68, 70.8%). Participants overall felt there was a need for online interactive assessments, more online resources that have been trialled for use via telehealth, accessible formats for resources for people with aphasia and clear instructions for how people with aphasia can access resources. CONCLUSIONS: This study provides new insights into the current use of telehealth assessment with people with aphasia in the United Kingdom and directions for future research. Barriers and facilitators identified can support the implementation of telehealth assessment in SLT services. WHAT THIS PAPER ADDS: What is already known on the subject The use of telehealth in speech and language therapy has advantages in terms of access to care, cost-effectiveness and satisfaction with care. However, little is known about the use of telehealth in aphasia rehabilitation in the United Kingdom, especially in the area of assessment and outcome measurement. What this paper adds to existing knowledge This study identified that the majority (>80%) of aphasia therapists used telehealth during the COVID-19 pandemic and >90% planned to continue to use telehealth in the future. A need was identified for existing measures to be tested for administration via telehealth and for training, resources (e.g., online interactive assessments) and materials (e.g., accessible formats for people with aphasia). What are the potential or actual clinical implications of this work? To facilitate the successful implementation of telehealth assessment, there is a need for measures validated for use via telehealth and more online resources that have been trialled for use via telehealth.

Impact of COVID-19 on clinical practice of UK-based speech and language therapists working with school-aged children with neurodisability and oropharyngeal dysphagia: A survey.

BACKGROUND: The COVID-19 pandemic and response changed clinical service delivery and practice for speech and language therapists (SLTs) in the United Kingdom. SLTs work with children with neurodisability regarding both difficulties with their communication and eating and drinking skills (oropharyngeal dysphagia). This survey aimed to specifically explore the impact of the COVID-19 pandemic on SLT practice for school-aged children with dysphagia. METHODS: UK-based SLTs working with school-aged children with neurodisability and oropharyngeal dysphagia were recruited to share their perceptions on the impact of COVID-19 on practice. Four questions focusing on COVID-19 impact were part of a larger online survey exploring SLT clinical practice regarding mealtime management of children with neurodisability and oropharyngeal dysphagia, which included demographic information, service delivery, assessment and intervention practices. COVID-19 impact questions were a mixture of multiple choice and free text responses. The survey was disseminated using professional networks and social media, between 14 May and 30 July 2021. Data were analysed using descriptive statistics and qualitative content analysis. RESULTS: One hundred and two participants answered at least one of the four COVID-19 questions. Eighty-two per cent of SLTs either agreed or strongly agreed that COVID-19 impacted on service delivery to children and families. Negative impacts on service delivery included school absences/closures, home visiting restrictions, families declining input and/or having barriers to telehealth use and the impact of mask wearing on interactions. Positive impacts included increased telehealth access and skills, increased contact with families and focus on children's eating and drinking function within the home environment. Participants aimed to maintain the increased contact with families alongside a hybrid service delivery approach of in-person and virtual appointments. CONCLUSIONS: This survey provides novel information capturing SLT practice change across two waves of COVID-19 and return to in-person practice for UK children with neurodisability.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs.

BACKGROUND: After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context. AIMS: (1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy. METHODS & PROCEDURES: A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis. OUTCOMES & RESULTS: The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general. CONCLUSIONS & IMPLICATIONS: The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require. WHAT THIS PAPER ADDS: What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

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.

Description and Effectiveness of Communication Partner Training in TBI: A Systematic Review.

OBJECTIVES: To evaluate the current evidence on communication partner training and its effectiveness on outcomes for people with traumatic brain injury (TBI) and/or their communication partners. METHODS: Information sources: Systematic searches of 9 databases (AMED, CINAHL, EMBASE, Medline/EBSCOHOST, PsycINFO, PsycBITE, PsycARTICLES, PubMed, and Scopus) from database inception to February 2019. Eligibility criteria: Empirical studies on interventions for adult communication partners where the primary focus of the program (>50%) was on improving communication skills of people with TBI and/or communication partners. Data: Participants, characteristics of the training, outcome measures, and findings. Risk of bias: Standard checklists were used for methodological quality (PEDro, ROBiN-T) and intervention description (TIDieR). Synthesis: Narrative synthesis and effect sizes (Cohen's d) for group-level studies. OUTCOMES: Ten articles (describing 8 studies) met eligibility criteria: 3 randomized controlled trials, 2 nonrandomized controlled trials, and 3 single-case experimental designs. Studies included a total of 258 people with TBI and 328 communication partners; however, all but one study had fewer than 65 participants. Methodological quality varied and intervention description was poor. Three studies in the final synthesis (n = 41 communication partners, n = 36 people with TBI) reported positive intervention effects. Effect sizes in group studies were d = 0.80 to 1.13 for TBI and d = 1.16 to 2.09 for communication partners. CONCLUSIONS: The articles provided encouraging, though limited, evidence for training communication partners. Greater methodological rigor, more clearly described interventions, and consistent use of outcome measures and follow-up after treatment are needed. Further research on this topic is warranted.

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.

Current practices and beliefs regarding supporting dating skills in rehabilitation for traumatic brain injury: a survey study.

BACKGROUND: Relationships are important to quality of life after traumatic brain injury (TBI). However, there has been limited research into how to support dating skills or how professionals view this area. METHOD: An online 52-item survey was developed and sent to professionals in the UK involved in rehabilitation after TBI. Recruitment was through professional networks, special interest groups and social media. RESULTS: 125 participants from a range of professions completed the survey. Many agreed that dating skills are important in rehabilitation (81.6%), but fewer (51.2%) reported engaging in this work. Psychologists, SLTs and OTs were identified as well placed to address dating skills. Case managers also appeared aware of this work. Participants reported using a range of activities to address dating skills, including managing disinhibited behavior and teaching interaction skills. Perceived barriers were both personal and professional, including lack of resources and feeling embarrassed. CONCLUSION: This study has highlighted an awareness of the importance of dating in brain injury, but professionals face multiple barriers to supporting dating skills. It is possible to draw on recommendations from related areas, including rehabilitation for cognitive communication difficulties and sexual dysfunction with further research to specifically link these areas to dating skills.

'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.

"Now I Am Myself": Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial.

Aphasia, a language disability, can profoundly affect a person's mood and identity. The experiences of participants who received Solution-Focused Brief Therapy, a psychological intervention, were explored in the Solution-Focused brief therapy In poststroke Aphasia (SOFIA) Trial. Thirty participants with chronic aphasia, 14 with severe aphasia, participated in in-depth interviews that were analyzed using framework analysis. Two overarching themes emerged: valued therapy components (exploring hopes, noticing achievements, companionship, sharing feelings, and relationship with therapist) and perceptions of progress (mood, identity, communication, relationships, and independence). Participants were categorized into four groups: (a) "changed," where therapy had a meaningful impact on a person's life; (b) "connected," where therapy was valued primarily for companionship; (c) "complemental," where therapy complemented a participant's upward trajectory; and (d) "discordant," where therapy misaligned with participants' preference for impairment-based language work. This study suggests that it is feasible to adapt a psychological therapy for people with aphasia, who perceive it as valuable.

The effects of a dialogue-based intervention to promote psychosocial well-being after stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of a dialogue-based intervention targeting psychosocial well-being at 12 months post-stroke. DESIGN: Multicenter, prospective, randomized, assessor-blinded, controlled trial with two parallel groups. SETTING: Community. SUBJECTS: Three-hundred and twenty-two adults (⩾18 years) with stroke within the last four weeks were randomly allocated into intervention group (n = 166) or control group (n = 156). INTERVENTIONS: The intervention group received a dialogue-based intervention to promote psychosocial well-being, comprising eight individual 1-1½ hour sessions delivered during the first six months post-stroke. MAIN MEASURES: The primary outcome measure was the General Health Questionnaire-28 (GHQ-28). Secondary outcome measures included the Stroke and Aphasia Quality of Life Scale-39g, the Sense of Coherence scale, and the Yale Brown single-item questionnaire. RESULTS: The mean (SD) age of the participants was 66.8 (12.1) years in the intervention group and 65.7 (13.3) years in the control group. At 12 months post-stroke, the mean (SE) GHQ-28 score was 20.6 (0.84) in the intervention group and 19.9 (0.85) in the control group. There were no between-group differences in psychosocial well-being at 12 months post-stroke (mean difference: -0.74, 95% confidence interval (CI): -3.08, 1.60). The secondary outcomes showed no statistically significant between-group difference in health-related quality of life, sense of coherence, or depression at 12 months. CONCLUSION: The results of this trial did not demonstrate lower levels of emotional distress and anxiety or higher levels of health-related quality of life in the intervention group (dialogue-based intervention) as compared to the control group (usual care) at 12 months post-stroke.

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

PRIMARY OBJECTIVE: To explore the clinical practice of communication partner training by Speech and Language Therapists for people with traumatic brain injury in the UK. STUDY DESIGN: Online 97-item survey which addressed the practice of training both familiar and unfamiliar communication partners, and barriers and facilitators to implementation informed by the Theoretical Domains Framework. PARTICIPANTS: 169 Speech and Language Therapists from private and public settings in the UK. RESULTS: While 96% reported training familiar communication partners, only 58% reported training unfamiliar communication partners. Therapists reported providing communication partner training consistent with best practice 43% of the time. Evidence-based published programmes were used by 13.8% and 19.9% of participants for training familiar and unfamiliar partners, respectively. Therapists reported using outcomes for familiar and unfamiliar communication partners 83% and 78% of the time. The most frequently reported barrier was lack of behavioral regulation (e.g., planning). Most frequent perceived facilitators were clinicians wanting to deliver communication partner training and that training was part of therapists' professional role (social professional role and identity). CONCLUSIONS: Therapists were motivated to deliver communication partner training but reduced capability affected implementation. Further support to clinicians on outcome measurement with materials to develop workplace systems to monitor implementation is needed.

Psychometric properties of discourse measures in aphasia: acceptability, reliability, and validity.

BACKGROUND: Discourse in adults with aphasia is increasingly the focus of assessment and therapy research. A broad range of measures is available to describe discourse, but very limited information is available on their psychometric properties. As a result, the quality of these measures is unknown, and there is very little evidence to motivate the choice of one measure over another. AIMS: To explore the quality of a range of discourse measures, targeting sentence structure, coherence, story structure and cohesion. Quality was evaluated in terms of the psychometric properties of acceptability (data completeness and skewness), reliability (inter- and intra-rater), and validity (content, convergent, discriminant and known groups). METHODS & PROCEDURES: Participants with chronic mild-to-moderate aphasia were recruited from community groups. They produced a range of discourses which were grouped into Cinderella and everyday discourses. Discourses were then transcribed orthographically and analyzed using macro- and microlinguistic measures (Story Grammar, Topic Coherence, Local Coherence, Reference Chains and Predicate Argument Structure-PAS). Data were evaluated against standard predetermined criteria to ascertain the psychometric quality of the measures. OUTCOMES & RESULTS: A total of 17 participants took part in the study. All measures had high levels of acceptability, inter- and intra-rater reliability, and had good content validity, as they could be related to a level of the theoretical model of discourse production. For convergent validity, as expected, 8/10 measures correlated with the Western Aphasia Battery-Revised (WAB-R) spontaneous speech scores, and 7/10 measures correlated with the Kissing and Dancing Test (KDT) scores (r ≥ 0.3), giving an overall positive rating for construct validity. For discriminant validity, as predicted, all measures had low correlations with Raven's Coloured Progressive Matrices (RCPM) and WAB-R Auditory Verbal Comprehension scores (r < 0.3), giving an overall positive rating for construct validity. Finally, for known groups validity, all measures indicated a difference between speakers with mild and moderate aphasia except for the Local Coherence measures. Overall, Story Grammar, Topic Coherence, Reference Chains and PAS emerged as the strongest measures in the current study because they achieved the predetermined thresholds for quality in terms of each of the psychometric parameters profiled. CONCLUSIONS & IMPLICATIONS: The current study is the first to psychometrically profile measures of discourse in aphasia. It contributes to the field by identifying Story Grammar, Topic Coherence, Reference Chains and PAS as the most psychometrically robust discourse measures yet profiled with speakers with aphasia. Until further data are available indicating the strength of other discourse measures, caution should be applied when using them.

Supporting people with aphasia to 'settle into a new way to be': speech and language therapists' views on providing psychosocial support.

BACKGROUND: People with aphasia are at risk of becoming depressed and isolated. Online surveys have found that the majority of speech and language therapists (SLTs) lack confidence in addressing the psychological needs of people with aphasia. AIMS: To explore how SLTs conceptualize the scope of their role; barriers and facilitators to SLTs addressing psychosocial needs; and SLTs' experiences of specialist training and support, and working with mental health professionals (MHPs). METHODS & PROCEDURES: Focus groups were conducted in stroke healthcare settings. Purposive sampling was used when selecting sites so as to capture a range of experiences. Results were analysed using framework analysis. OUTCOMES & RESULTS: Twenty-three SLTs took part in six focus groups. Participants' psychosocial work included counselling-type interactions, psycho-education, working with families, facilitating peer support and training other healthcare professionals. There was lack of consensus on the scope of the SLT role. Many expressed a sense of conflict, both perceiving it as valuable to spend time addressing psychological well-being, while simultaneously feeling uneasy if they deviated from 'direct SLT' work. Barriers to addressing psychosocial well-being were: emotionally challenging nature of this work, particularly for those who felt unsupported; caseload and time pressures; attitudes of senior managers and commissioners; difficulties measuring and documenting more 'fluid' psychosocial work; and the complexity of the needs and backgrounds of some patients. Enabling factors were: specialist ongoing support; peer support from colleagues; experience; support of management; and personal belief. Specialist training was valued. It changed how participants viewed the therapist-client relationship (more client led); the assessment and goal-setting process; and gave them more confidence to acknowledge client emotions. However, many felt that there was a need for ongoing specialist advice, and to be able to see approaches modelled for this client group. In terms of MHPs, a subset of stroke-specialist clinical psychologists worked directly with people with marked aphasia and families, as well as supporting the multidisciplinary team to provide holistic care. However, a main theme was that participants perceived many MHPs did not consider people with aphasia as 'appropriate candidates' for psychological input. CONCLUSIONS & IMPLICATIONS: All participants cared about the emotional well-being of their clients; however, they identified a number of barriers to people with aphasia receiving appropriate psychological support. A cultural shift, whereby psychological care for people with aphasia is seen as valuable, feasible and necessary, delivered collaboratively by SLTs, MHPs and the wider team, may improve services.

Cultural adaptation and psychometric testing of The Scenario Test UK for people with aphasia.

BACKGROUND: This study explores the psychometric properties of The Scenario Test UK, a culturally adapted version of the Dutch original (The Scenario Test) developed by van der Meulen et al. in 2010, which evaluates functional, daily-life communication in aphasia. The Scenario Test assesses communication in an interactive context with a supportive communication partner. AIMS: To evaluate the reliability (internal consistency, interrater and test-retest reliability) and construct validity (convergent, discriminant and known-groups validity) of The Scenario Test UK. METHODS & PROCEDURES: The Scenario Test UK and other language, cognition and praxis assessments were administered to persons with aphasia after stroke (3+ months post-stroke) and to non-aphasic controls. Participants were recruited primarily through community stroke groups. Measures were completed in an interview format. Standard psychometric criteria were used to evaluate reliability and construct validity. OUTCOMES & RESULTS: A total of 74 participants with aphasia and 20 participants without aphasia took part in The Scenario Test UK. The test showed high levels of reliability. Internal consistency (Cronbach's α = 0.92), interrater reliability (ICC = 0.95) and test-retest reliability (ICC = 0.96) were excellent. Interrater agreement in scores on the individual items ranged from good to excellent (κ = 0.41-1.00) for all but two items (item 4c κ = 0.38, item 6c κ = 0.36). The test demonstrated good levels of convergent (ρ = 0.37-0.75) and discriminant validity (ρ = -0.04 to 0.23). There was strong evidence for known groups validity (U = 132.50, p < .001), with those with aphasia scoring significantly lower [median (interquartile range-IQR) = 47 (39.8-51.0)] than those without aphasia [53 (52-54)]. CONCLUSIONS & IMPLICATIONS: The data support the reliability and validity of the Scenario Test UK as an assessment of functional, daily-life communication for persons with aphasia. Further testing is needed in independent samples on the measure's psychometric properties, including its sensitivity to change. Pending this testing, The test can be used as an assessment tool to evaluate communication skills with people with aphasia, to guide goal setting for therapy and to measure outcomes in response to therapy.

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.

How do speech-and-language therapists address the psychosocial well-being of people with aphasia? Results of a UK online survey.

BACKGROUND: The psychosocial impact of stroke and aphasia is considerable. AIMS: To explore UK speech-and-language therapists' (SLTs) clinical practice in addressing the psychological and social needs of people with aphasia, including their experiences of working with mental health professionals. METHODS & PROCEDURES: A 22-item online survey was distributed to UK SLTs via the British Aphasiology Society mailing list and Clinical Excellence Networks. Results were analysed using descriptive statistics and qualitative content analysis. OUTCOMES & RESULTS: UK SLTs (n = 124) overwhelmingly considered that addressing psychological well-being (93%) and social participation (99%) was part of their role. To achieve this, they frequently/very frequently used supportive listening (100%) and selected holistic goals collaboratively with clients (87%), including social goals (83%). However, only 42% felt confident in addressing the psychological needs of clients. The main barriers to addressing psychosocial well-being were time/caseload pressures (72%); feeling under-skilled/lack of training (64%), and lack of ongoing support (61%). The main barriers to referring on to mental health professionals were that mental health professionals were perceived as under-skilled when working with people with aphasia (44%); were difficult to access (41%); and provided only a limited service (37%). A main theme from the free-text responses was a concern that those with aphasia, particularly more severe aphasia, received inadequate psychological support due to the stretched nature of many mental health services; mental health professionals lacking skills working with aphasia; and SLTs lacking the necessary time, training and support. The main enablers to addressing psychosocial well-being were collaborative working between SLTs and stroke-specialist clinical psychologists; SLTs with training in providing psychological and social therapy; and ongoing support provided by the voluntary sector. CONCLUSIONS & IMPLICATIONS: The vast majority of SLTs consider the psychosocial well-being of their clients, and work collaboratively with people with aphasia in selecting holistic goals. It is, however, of concern that most respondents felt they lacked confidence and received insufficient training to address psychological well-being. In order to improve psychological services for this client group, there is a strong case that stroke-specialist mental health professionals should strive to make their service truly accessible to people with even severe aphasia, which may involve working more closely with SLTs. Further, improving the skills and confidence of SLTs may be an effective way of addressing psychological distress in people with aphasia.

Reviewing the quality of discourse information measures in aphasia.

BACKGROUND: Discourse is fundamental to everyday communication, and is an increasing focus of clinical assessment, intervention and research. Aphasia can affect the information a speaker communicates in discourse. Little is known about the psychometrics of the tools for measuring information in discourse, which means it is unclear whether these measures are of sufficient quality to be used as clinical outcome measures or diagnostic tools. AIMS: To profile the measures used to describe information in aphasic discourse, and to assess the quality of these measures against standard psychometric criteria. METHODS & PROCEDURES: A scoping review method was employed. Studies were identified using a systematic search of Scopus, Medline and Embase databases. Standard psychometric criteria were used to evaluate the measures' psychometric properties. MAIN CONTRIBUTION: The current review summarizes and collates the information measures used to describe aphasic discourse, and evaluates their quality in terms of the psychometric properties of acceptability, reliability and validity. Seventy-six studies described 58 discourse information measures, with a mean of 2.28 measures used per study (SD = 1.29, range = 1-7). Measures were classified as 'functional' measures (n = 33), which focused on discourse macrostructure, and 'functional and structural' measures (n = 25), which focused on micro-linguistic and macro-structural approaches to discourse. There were no reports of the acceptability of data generated by the measures (distribution of scores, missing data). Test-retest reliability was reported for just 8/58 measures with 3/8 > 0.80. Intra-rater reliability was reported for 9/58 measures and in all cases percentage agreement was reported rather than reliability. Per cent agreement was also frequently reported for inter-rater reliability, with only 4/76 studies reporting reliability statistics for 12/58 measures; this was generally high (>.80 for 11/12 measures). The majority of measures related clearly to the discourse production model indicating content validity. A total of 36/58 measures were used to make 41 comparisons between participants with aphasia (PWA) and neurologically healthy participants (NHP), with 31/41 comparisons showing a difference between the groups. Four comparisons were made between discourse genres, with two measures showing a difference between genres, and two measures showing no difference. CONCLUSIONS: There is currently insufficient information available to justify the use of discourse information measures as sole diagnostic or outcome measurement tools. Yet the majority of measures are rooted in relevant theory, and there is emerging evidence regarding their psychometric properties. There is significant scope for further psychometric strengthening of discourse information measurement tools.

A systematic review of the impact of stroke on social support and social networks: associated factors and patterns of change.

OBJECTIVE: Identify what factors are associated with functional social support and social network post stroke; explore stroke survivors' perspectives on what changes occur and how they are perceived. DATA SOURCES: The following electronic databases were systematically searched up to May 2015: Academic Search Complete; CINAHL Plus; E-journals; Health Policy Reference Centre; MEDLINE; PsycARTICLES; PsycINFO; and SocINDEX. REVIEW METHODS: PRISMA guidelines were followed in the conduct and reporting of this review. All included studies were critically appraised using the Critical Appraisal Skills Program tools. Meta-ethnographic techniques were used to integrate findings from the qualitative studies. Given the heterogeneous nature of the quantitative studies, data synthesis was narrative. RESULTS: Seventy research reports met the eligibility criteria: 22 qualitative and 48 quantitative reporting on 4,816 stroke survivors. The qualitative studies described a contraction of the social network, with non-kin contact being vulnerable. Although family were more robust network members, significant strain was observed within the family unit. In the quantitative studies, poor functional social support was associated with depression (13/14 studies), reduced quality of life (6/6 studies) and worse physical recovery (2/2 studies). Reduced social network was associated with depression (7/8 studies), severity of disability (2/2 studies) and aphasia (2/2 studies). Although most indicators of social network reduced post stroke (for example, contact with friends, 5/5 studies), the perception of feeling supported remained relatively stable (4/4 studies). CONCLUSION: Following a stroke non-kin contact is vulnerable, strain is observed within the family unit, and poor social support is associated with depressive symptoms.