Perceptions of Communication and Mobility Recovery Among Stroke Survivors With and Without Aphasia.

Self-perceived recovery after stroke can substantially impact quality of life. Yet, a disability paradox exists whereby disability and perceived recovery do not align. This study explored stroke survivors' perceptions of their communication and mobility recovery, including perceived facilitators and barriers. Potential differences between the experiences of participants with aphasia (PWA) and participants without aphasia (PWOA) were also examined to explore the impact of communication disability on recovery experience. Semi-structured interviews were conducted with 17 adults with stroke 3 months after discharge from inpatient rehabilitation. Qualitative data in the form of interview transcripts were analyzed using thematic content analysis. Participants described their communication recovery primarily in terms of word-finding difficulty and slowed language formulation; they described their mobility recovery in terms of their ability to walk, their use of an assistive device, or their ability to participate in pre-stroke activities. Facilitators to recovery were described in the areas of (1) family involvement, (2) rehabilitation services and professionals, (3) personal factors, and (4) the need for self-reliance. Barriers were expressed in the domains of (1) physical difficulties, (2) communication difficulties, and (3) psychological difficulties. Key findings from this study include perceived needs for a high intensity of rehabilitation, earlier implementation of communication partner training for families of stroke survivors with communication impairments, and consideration of factors outside of stroke when tailoring intervention to the individual. Overall, these findings suggest a continued need for individuation rather than standardization of care, with an eye to both impairment and broader quality of life factors.

Barriers and facilitators to outcome measurement and treatment practices in aphasia rehabilitation in the USA: a mixed methods approach using the Theoretical Domains Framework.

PURPOSE: To identify clinician-perceived barriers and facilitators to the delivery of outcome measurement and evidence-based treatment practices and integration of these practices in aphasia rehabilitation. MATERIALS AND METHODS: Using a convergent mixed methods design, aphasia clinicians (n = 87) across care settings in the United States completed an online survey designed within the Theoretical Domains Framework (TDF). Participants responded to open-ended questions and rated Likert scale statements. Qualitative data were analyzed using content analysis and quantitative data were summarized using descriptive statistics. RESULTS: Factors related to the TDF domain of "environmental context and resources" (priority and productivity demands; characteristics of resources) were cited as primary barriers in 70% of qualitative responses for both outcome and treatment practices and were consistent with Likert rating statements. Facilitators were associated with TDF domains of "memory, attention, decision-making" (decision-making processes), "knowledge" (awareness of evidence) and "social influences" (client and caregiver preferences). CONCLUSIONS: Organizational-level factors and the misalignment of the research evidence with clinical needs are barriers to delivering evidence-based care in aphasia rehabilitation. Theoretically informed strategies such as establishing organizational infrastructure for practice change, developing clinically relevant evidence through research-practice partnerships, and implementing algorithms to support clinical decision-making can address barriers and leverage facilitators.

Rehabilitation research needs to engage clinical partners and consider the healthcare context to provide the field with evidence-based outcome measures and treatment recommendations that meet the needs of the clinical environment.Clinical decision-making tools and algorithms have potential to support systematic, evidence informed care.Future implementation efforts need to test strategies that go beyond knowledge and skills training.Clinicians are optimistic for change in clinical practice within themselves and the profession.

How a Power Differential Between Clinicians and Researchers Contributes to the Research-to-Practice Gap.

PURPOSE: The purpose of this article is to contend that there is a power differential between researchers and clinicians where researchers are the primary creators of knowledge and clinicians are the primary consumers of knowledge. Rooted in a sociological model illustrating interacting levels of power at macro-, meso-, and microlevels, we argue that authentic research-practice partnerships and clinician-researcher collaborations can mitigate this power differential. CONCLUSIONS: Clinicians and researchers in our field have vastly different responsibilities and priorities that impact our ability to work collaboratively to solve the most pressing problems for the clients we serve. Although some current research practices may reinforce a power differential causing clinicians to feel less than and to only consume knowledge, there are examples of successful collaborations where this power differential is mitigated. These examples can contribute meaningfully to the dialogue on research-practice partnerships, with the goal of improving outcomes for the clients we serve.

Acoustic and Kinematic Assessment of Motor Speech Impairment in Patients With Suspected Four-Repeat Tauopathies.

PURPOSE: The aim of this study was to use acoustic and kinematic speech measures to characterize type of motor speech impairment-apraxia of speech (AOS) versus dysarthria-in individuals with four-repeat tauopathy (4RT)-associated syndromes, including nonfluent variant primary progressive aphasia (nfvPPA), primary progressive AOS (PPAOS), corticobasal syndrome (CBS), and progressive supranuclear palsy syndrome (PSPs). METHOD: Twenty patient participants were recruited and stratified into two groups: (a) a motor-speech-impaired group of individuals with nfvPPA, PPAOS, CBS, or PSPs and suspected 4RT pathology ("MSI+") and (b) a non-motor-speech-impaired group of individuals with logopenic variant primary progressive aphasia ("MSI-"). Ten healthy, age-matched controls also participated in the study. Participants completed a battery of speech tasks, and 15 acoustic and kinematic speech measures were derived. Quantitative speech measures were grouped into feature categories ("AOS features," "dysarthria features," "shared features"). In addition to quantitative speech measures, two certified speech-language pathologists made independent, blinded auditory-perceptual ratings of motor speech impairment. A principal component analysis (PCA) was conducted to investigate the relative contributions of quantitative features. RESULTS: Quantitative speech measures were generally concordant with independent clinician ratings of motor speech impairment severity. Hypothesis-driven groupings of quantitative measures differentiated predominantly apraxic from predominantly dysarthric presentations within the MSI+ group. PCA results provided additional evidence for differential profiles of motor speech impairment in the MSI+ group; heterogeneity across individuals is explained in large part by varying levels of overall severity-captured by the shared feature variable group-and degree of apraxia severity, as measured by the AOS feature variable group. CONCLUSIONS: Quantitative features reveal heterogeneity of MSI in the 4RT group in terms of both overall severity and subtype of MSI. Results suggest the potential for acoustic and kinematic speech assessment methods to inform characterization of motor speech impairment in 4RT-associated syndromes. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21401778.

Prologue: Implementation Science in CSD and Starting Where You Are.

In this prologue, we introduce readers to the Forum: Clinicians and Researchers Navigating Implementation Science in CSD. Implementation science (IS), or the study of the adoption of evidence-based practice in real-world settings, is a key area of development in communication sciences and disorders (CSD). The goal of this forum was to show by example how researchers and clinicians are collaborating to begin to apply IS in CSD. This goal culminated in a scoping review of IS in CSD, a tutorial on incorporating IS into clinical practice research, three articles on stakeholder engagement, and three examples of IS studies in CSD included in this forum. We hope this forum helps clinicians and researchers to begin wherever they are in their knowledge and understanding of IS in CSD.

Implementation Science Research in Communication Sciences and Disorders: A Scoping Review.

PURPOSE: The purpose of this study was to complete a scoping review of implementation science (IS) research in communication sciences and disorders (CSD) over time and to determine characteristics of IS research in CSD. METHOD: A scoping review was conducted of PubMed and Education Resources Information Center for sources published in English that (a) included CSD practitioners, (b) addressed IS research, and (c) identified a specific evidence-based practice. Resulting sources were systematically examined for study aim, patient populations, implementation framework utilized, setting of the study, implementation strategy examined, and implementation outcome measured. RESULTS: The majority of the 82 studies that underwent a full-text review (80.5%) were published in 2014 or later. One fourth of the studies were concept papers, and another one fourth focused on context assessment (25.6% of studies, each), 11% focused on designing implementation strategies, and 36.6% focused on testing implementation strategies. The patient population most frequently represented aphasia (21.3%), and most studies (34.4%) were conducted in inpatient medical settings. Nearly half (42.6%) of the nonconcept studies lacked an IS framework. Among implementation strategies identified, approximately one third of studies focused on education and/or training plus another strategy and one fourth focused on education and/or training alone. Implementation outcomes measured typically represented early stages of implementation. CONCLUSIONS: This scoping review of IS research in CSD described the landscape of IS studies in CSD. IS is intersecting with CSD at a rapid rate, especially since 2014. Future IS research in CSD should adopt an implementation framework a priori and consider the broad range of implementation strategies and outcomes to support the uptake of research into typical practice settings.

Cue responsiveness as a measure of emerging language ability in aphasia.

BACKGROUND: Prior research suggests that initial aphasia severity, lesion size, and lesion location are the most salient factors in predicting recovery outcomes. While these factors provide important prognostic information, information that is individualized and readily available to clinicians is limited. Deficits in naming are common to all aphasia types and are routinely targeted in aphasia assessment and treatment, with cues provided to facilitate lexical retrieval. OBJECTIVES: In this study, we examine aphasia recovery factors that are readily available to clinicians, examining whether a person's ability to improve naming with cues, indicating "stimulability," will be predictive of future word retrieval. METHODS: Ten participants with aphasia following a left-hemisphere stroke participated in initial assessment, seven of whom met criteria for longitudinal assessment. Stroke and early clinical recovery data were collected for all participants. At four timepoints over one year we evaluated longitudinal participants' naming ability and measured the proportion of successful lexical retrieval with the presentation of phonemic, feature, and sentence cues. RESULTS: For all participants, multiple descriptive factors regarding recovery, including lesion information, information from the acute inpatient timeframe, and communication opportunities, were examined. For individuals followed longitudinally, naming stimulability did not consistently predict naming accuracy at the subsequent assessment timepoint. Individuals' attempts at naming emerged as a metric related to future naming performance warranting further evaluation. CONCLUSIONS: Multiple factors related to recovery must be considered when providing prognostic information. Naming stimulability and attempts at naming provide some information regarding future performance, but are not consistently reliable across timepoints.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia.

PURPOSE: Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach. METHOD: Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision. RESULTS: Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery. CONCLUSIONS: Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Implementing a Standardized Language Evaluation in the Acute Phases of Aphasia: Linking Evidence-Based Practice and Practice-Based Evidence.

The research to practice gap is a significant problem across all disciplines of healthcare. A major challenge associated with the adoption of evidence into routine clinical care is the disconnect between findings that are identified in a controlled research setting, and the needs and challenges of a real-world clinical practice setting. Implementation Science, which is the study of methods to promote research into clinical practice, provides frameworks to promote the translation of findings into practice. To begin to bridge the research-practice gap in assessing recovery in individuals with aphasia in the acute phases of recovery following stroke, clinicians in an acute care hospital and an inpatient rehabilitation hospital followed an implementation science framework to select and implement a standardized language assessment to evaluate early changes in language performance across multiple timepoints. Using a secure online database to track patient data and language metrics, clinically-accessible information was examined to identify predictors of recovery in the acute phases of stroke. We report on the feasibility of implementing such standardized assessments into routine clinical care via measures of adherence. We also report on initial analyses of the data within the database that provide insights into the opportunities to track change. This initiative highlights the feasibility of collecting clinical data using a standardized assessment measure across acute and inpatient rehabilitation care settings. Practice-based evidence may inform future research by contributing pilot data and systematic observations that may lead to the development of empirical studies, which can then feed back into clinical practice.

Implementing a Standardized Assessment Battery for Aphasia in Acute Care.

In this article, the implementation of a standardized assessment battery for the evaluation of language in an acute care setting is described. Following an institutional shift to adopt electronic medical records, researchers and clinicians worked together to develop a technology-assisted evaluation of aphasia that would be used to assess all patients admitted to our facility with stroke. The project goal was to devise a clinical process to improve aphasia diagnosis and evaluation while remaining feasible within constraints imposed by the acute care setting and the electronic medical record. Utilizing frameworks from implementation science, the four key phases were: (1) initial considerations of the host setting, (2) creation of a structure for implementation, (3) maintenance of this structure once implementation began, and (4) improvement for future applications. A pilot implementation demonstrated that establishing and executing a minimum standardized assessment for aphasia in acute care is feasible. Retrospective medical record review of 50 aphasia evaluations in the setting of first incidence of left hemisphere stroke affecting the middle cerebral artery (25 preimplementation and 25 postimplementation) revealed that information content of medical notes was more consistent and complete postimplementation than preimplementation. Clinical implications and future directions are discussed.

Collection of Patients' Disability Status by Healthcare Organizations: Patients' Perceptions and Attitudes.

Recent policies call for healthcare organizations to consistently document patients' disability status for the purpose of tracking the quality of care experienced by patients with disabilities. The purpose of the study was to explore patients' attitudes toward healthcare organizations collecting disability status. We surveyed a convenience sample of patients in three outpatient clinics, including primary care and rehabilitation clinics. A total of 303 patients participated; 49% self-identified as disabled, 59% were female and the mean age was 52 years. The majority of participants (88%) either agreed or strongly agreed that it is important for healthcare organizations to collect information about disabilities; 77% stated that they were comfortable or very comfortable with healthcare organizations collecting this information. By contrast, we found that almost a quarter of participants had concerns with front desk staff collecting disability status information. When we presented disability questions endorsed by the Health and Human Services Department, over a quarter of participants (28%) felt that the questions were not inclusive of all disability categories. Although patients are supportive of healthcare organizations collecting disability status information, concerns exist regarding how the information is collected and which categories are included, suggesting the need for continued development of evidence-based, patient-centered methods and questions.