Communication support in care homes for older adults: Views and reported practices of speech and language therapists and care home activities staff in the UK.

BACKGROUND: Speech and language therapists (SLTs) and care home activities staff play key roles in managing and supporting the communication needs of older residents in care homes. However, the current practice and perspectives of these two professions in the United Kingdom has not been examined. AIMS: To investigate the practice patterns and views of SLTs and activities staff working in UK care homes for older adults in relation to residents' communication needs. METHODS AND PROCEDURES: Two online surveys, with 63 questions (SLT survey) and 46 questions (activities staff survey) in total, were created using the online platform Qualtrics. Participants were asked to consider their routine practice before COVID-19. Results were analysed using descriptive statistics and qualitative content analysis. OUTCOMES AND RESULTS: A total of 116 valid responses were received from SLTs and 29 valid responses from activities staff. A high level of communication needs in care homes was reported by both participant groups, as was insufficient time and resources and lack of managerial encouragement in this area. SLTs reported that the majority of referrals to their service from care homes was for swallowing needs (70%). Cognitive communication difficulty was the most commonly reported communication need by SLTs (65%). Most SLTs (73%-87%) provided some level of communication intervention and considered management of residents' communication needs to be both part of the SLT role and a good investment of their time. Lack of confidence setting goals and providing direct intervention for communication needs was reported, with 25% feeling stressed at the thought of this. The main themes from free text responses about SLT service improvement were increased staff training, funding (of resources and specialist posts) and changes to service provision (referral criteria and accessibility/awareness of SLT service). Hearing impairment was the communication need most commonly reported by activities staff (43%). Participants demonstrated relatively high awareness of communication difficulty in residents and reported high levels of knowledge and confidence identifying and supporting residents' communication. Most (79%-89%) considered identifying and supporting the communication needs of residents to be part of their role and expressed interest in receiving further training in communication support. The reported activities staff data set may be positively biased. CONCLUSIONS AND IMPLICATIONS: SLTs and activities staff were highly motivated to support the communication needs of care home residents. Increased training, time and resources dedicated to managing the communication needs of residents emerged as opportunities for service improvement across both data sets. WHAT THIS PAPER ADDS: What is already known on the subject There is a high level of communication need amongst older care home residents. Social interaction and relationships are important factors contributing to quality of life in this population and rely on successful communication. Speech and language therapists (SLTs) and activities staff play key roles in managing and supporting the communication needs of this client group, but the current practice and perspectives of these professions in the United Kingdom has not been examined. What this study adds A high level of communication need in care home residents was identified by both SLT and activities staff and both participant groups were motivated to address, identify and manage this need. However, insufficient time and resources, as well as a perceived lack of encouragement from managers to provide communication support/intervention, were reported by both groups. SLT practice was constrained by referral criteria and care pathways, which differed between services. Suggestions for SLT service improvement are reported. Clinical implications of this study Targeted, ongoing staff training is required in care homes to improve the communication environment and develop care home staff capacity to support residents' communication needs. There is also a call for service level improvements to increase the range of SLT practice in care homes, including a greater focus on communication needs and more specialist (e.g., dementia) SLT roles.

Tracheoesophageal Voice Therapy in Postlaryngectomy Rehabilitation: A Systematic Review.

BACKGROUND: Following total laryngectomy, surgical voice restoration is considered the optimal modality for re-establishing communication via tracheoesophageal voice. Yet beyond the insertion of a voice prosthesis to elicit voice production, there is suboptimal clinical knowledge of how to rehabilitate the perceptual quality of tracheoesophageal voice. This systematic review will identify and critically evaluate the quality and effectiveness of therapeutic interventions for tracheoesophageal voice. The findings of this review will inform the development of a novel tracheoesophageal voice therapy intervention. STUDY DESIGN: Systematic literature review carried out in accordance with PRISMA guidelines. METHODS: The review protocol was registered with PROSPERO. Eight electronic databases were searched using a prespecified search strategy. Records were independently screened by two reviewers against inclusion and exclusion criteria. Eligible studies were assessed for quality using the PEDro, ROBIN-T, and NHLBI critical appraisal tools. Data was extracted pertaining to participant characteristics and the content, dosage, intensity and outcomes of interventions. RESULTS: 6344 records were identified, of which 38 were included for full-text review. Six studies met the eligibility criteria for inclusion. Voice rehabilitation was not the primary focus in the majority of studies, and the risk of bias was identified across studies. There was significant heterogeneity in the interventions and outcome measures used within studies with insufficient detail provided on intervention content for tracheoesophageal voice. Evidence for the effectiveness of interventions was limited and inconsistent across studies. CONCLUSIONS: This review found that tracheoesophageal voice therapy is an under-researched area of clinical practice. Evidence from the small body of existing studies was not sufficiently robust to inform clinical practice at this time. This review highlights the necessity to develop and test interventions aimed at improving the perceptual quality of tracheoesophageal voice.

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

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

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

Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom.

BACKGROUND: Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented. AIMS: This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored. METHODS & PROCEDURES: An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis. OUTCOMES & RESULTS: Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP. CONCLUSIONS & IMPLICATIONS: This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion. WHAT THIS PAPER ADDS: What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.

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.

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 systematic review of language and communication intervention research delivered in groups to older adults living in care homes.

BACKGROUND: The communication skills of older adults living in care homes is an underexplored topic. Ageing can lead to reduced communication ability and activity; and in the care home environment there may also be fewer communication opportunities. This situation is likely to negatively impact well-being. Previous reviews have found evidence of the effectiveness of behavioural interventions in increasing well-being, but no systematic review to date has focused specifically on the evidence base for group language and communication interventions in this population. AIMS: To identify and evaluate the evidence for behavioural interventions with older adults, delivered in groups in care homes, that specifically included a language or communication activity. To explore the impact of such intervention on the specific domains of language, communication and social interaction. To determine whether behavioural mechanisms of action can be identified. METHODS & PROCEDURES: Embase, Medline, Ovid Nursing database, Psych info and CINAHL complete were searched and produced 158 records for screening, of which 22 remained for review. In order to identify and evaluate the quality of the evidence base presented the following research questions were posed: What research has been conducted in this area? What is the methodological quality of the studies identified? How complete is the intervention reporting? How was change measured in the domains of language, communication and social interaction? Is there evidence of efficacy, indicated by statistically significant improvement, in these domains? How did the interventions work? Synthesis tools employed included the PEDro-P Scale, the TIDieR checklist and the ITAX. MAIN CONTRIBUTION: A total of 22 studies met the criteria for review. One study used solely language or communication interventions, but the remaining 21 studies used behavioural interventions which incorporated language and communication activities to varying degrees. Studies fell into four broad intervention types: reminiscence or life review; cognitive stimulation; narrative or storytelling; and multi-modality group communication. The majority of studies were of fair methodological quality, with a moderate level of detail provided in treatment reporting. Statistically significant improvement was reported by authors in all four intervention types and across language, communication and social domains. Social interaction, social support and behavioural skills were the most consistent mechanisms of action in the reviewed behavioural interventions. CONCLUSIONS & IMPLICATIONS: Despite limitations in the evidence base, there are important positive signs for the beneficial effects of supporting language and communication in care homes. Blinding of assessors, and the accuracy and accessibility of statistical reporting are important areas to address in order to improve the quality of the evidence base. WHAT THIS PAPER ADDS: Ageing can lead to reduced communication ability and activity, and in the care home setting there may also be fewer communication opportunities. This situation is likely to negatively impact well-being. Previous reviews have found evidence of the effectiveness of behavioural interventions in increasing well-being. The communication skills of older adults living in care homes is an underexplored topic. No systematic review to date has focused specifically on the evidence base for group language and communication interventions in this population. This review reveals important positive signs for the beneficial effects of supporting language and communication in care homes. Social interaction, social support, and behavioural skills were the most consistent mechanisms of action in the reviewed behavioural interventions.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb and Sentence Deficits in Aphasia: Sentence Treatments.

PURPOSE: This review article synthesizes and evaluates the evidence for sentence production treatments in aphasia, systematically charting impairment-based and functional communication outcomes. It reports (a) the level of evidence and fidelity of sentence treatments; (b) the impact of treatment on production of trained and untrained verbs and sentences, functional communication, and discourse; and (c) the potential active ingredients of treatment. METHOD: The search included studies from January 1980 to June 2019. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to treatment methods used. RESULTS: Thirty-three studies were accepted into the review and predominantly constituted Level 4 evidence (e.g., case control studies and case series). Thirty studies (90%) described treatment in sufficient detail to allow replication, but dosage was poorly reported, and fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were mapping (10 studies: 30%), predicate argument structure treatment (six studies: 18%), and verb network strengthening treatment (five studies: 15%). Production of trained sentences improved for 83% of participants, and improvements generalized to untrained sentences for 59% of participants. Functional communication was rarely assessed, but discourse production improved for 70% of participants. CONCLUSIONS: The evidence for sentence treatments is predominantly generated from Level 4 studies. Treatments were effective for the majority of participants regarding trained sentence and discourse production. However, there is inconsistent use of statistical analysis to verify improvements, and diverse outcome measures are used, which makes interpretation of the evidence difficult. The quality of sentence treatment research would be improved by agreeing a core set of outcome measures and extended by ascertaining the views of participants on sentence treatments.

Creating a Theoretical Framework to Underpin Discourse Assessment and Intervention in Aphasia.

Discourse (a unit of language longer than a single sentence) is fundamental to everyday communication. People with aphasia (a language impairment occurring most frequently after stroke, or other brain damage) have communication difficulties which lead to less complete, less coherent, and less complex discourse. Although there are multiple reviews of discourse assessment and an emerging evidence base for discourse intervention, there is no unified theoretical framework to underpin this research. Instead, disparate theories are recruited to explain different aspects of discourse impairment, or symptoms are reported without a hypothesis about the cause. What is needed is a theoretical framework that would clarify the specific linguistic skills that create completeness, coherence, and complexity (i.e., richness) in discourse, and illuminate both the processes involved in discourse production and the reasons for breakdown. This paper reports a review and synthesis of the theoretical literature relevant to spoken discourse in aphasia discourse, and we propose a novel theoretical framework which unites these disparate sources. This framework is currently being tested as the foundation for Linguistic Underpinnings of Narrative in Aphasia (LUNA) treatment research. In this paper, we outline the novel framework and exemplify how it might be used to guide clinical practice and research. Future collaborative research is needed to develop this framework into a processing model for spoken discourse.

The City Gesture Checklist: The development of a novel gesture assessment.

BACKGROUND: People with aphasia rely on gesture more than healthy controls to get their message across, but use a limited range of gesture types. Gesture therapy is thus a potential avenue of intervention for people with aphasia. However, currently no gesture assessment evaluates how they use gesture. Such a tool could inform therapy targets and measure outcomes. In gesture research, many different coding categories are used to describe gesture forms and functions. These coding methods are prohibitively time-consuming to use in clinical practice. There is therefore a need for a 'quick and dirty' method of assessing gesture use. AIMS: To investigate current practice among UK-based clinicians (speech and language therapists) in relation to gesture assessment and therapy, to synthesize gesture-coding frameworks used in aphasia research, to develop a gesture checklist based on the synthesized coding frameworks suitable for use in clinical practice, and to investigate the interrater reliability (IRR) of the checklist among experienced and unfamiliar users. METHODS & PROCEDURES: The research team synthesized seven gesture-coding frameworks and trialled three resulting prototype checklists at a co-design workshop with 20 clinicians. Attending clinicians were also consulted about their current clinical gesture practice using a questionnaire. A final City Gesture Checklist (CGC) was developed based upon outcomes and feedback from the workshop. The IRR of the CGC was evaluated between the research team and 11 further clinicians within a second workshop. Both groups used the CGC to count gestures in video clips of people with aphasia talking to a conversation partner. MAIN CONTRIBUTION: A total of 18 workshop attendees completed the current practice questionnaire. Of these, 10 reported assessing gesture informally and five also used formal assessment. Gesture-coding synthesis highlighted six main categories of gesture form. Clinicians at the co-design workshop provided feedback on prototype checklists regarding the relevance and usability of the gesture categories, layout, use of images and instructions. A final version of the CGC was created incorporating their recommendations. The IRR for the CGC was moderate between both the researchers and clinicians. CONCLUSIONS & IMPLICATIONS: The CGC can be used to assess the types of gesture that people with aphasia produce. The IRR was moderate amongst both experienced users and new users who had received no training. Future research directions include investigating how to improve IRR, evaluating intra-rater reliability and sensitivity to change, and exploring use of the CGC in clinical practice. What this paper adds What is already known on the subject People with aphasia rely on gesture more than healthy speakers, yet use a more limited range of gesture types. Gesture therapy is used by clinicians with the aim of helping people with aphasia to compensate for their language impairment and/or to facilitate speech. What this paper adds to existing knowledge This study explores current gesture assessment practice among UK-based clinicians and synthesizes the coding categories used in the literature about gesture research in aphasia. It describes the development of a novel outcome measure, the CGC, and preliminary testing of its IRR. What are the potential or actual clinical implications of this work? This 'quick and dirty' tool enables clinicians to analyse and record the types of gesture produced by people with aphasia without the need for gesture coding. Preliminary findings suggest that clinicians can use it with a fair degree of reliability by following the checklist's written instructions.

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

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

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb Deficits in Aphasia: Verb-in-Isolation Treatments.

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

The influence of conversation parameters on gesture production in aphasia.

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

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.

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.

Integration of speech and gesture in aphasia.

BACKGROUND: Information from speech and gesture is often integrated to comprehend a message. This integration process requires the appropriate allocation of cognitive resources to both the gesture and speech modalities. People with aphasia are likely to find integration of gesture and speech difficult. This is due to a reduction in cognitive resources, a difficulty with resource allocation or a combination of the two. Despite it being likely that people who have aphasia will have difficulty with integration, empirical evidence describing this difficulty is limited. Such a difficulty was found in a single case study by Cocks et al. in 2009, and is replicated here with a greater number of participants. AIMS: To determine whether individuals with aphasia have difficulties understanding messages in which they have to integrate speech and gesture. METHODS & PROCEDURES: Thirty-one participants with aphasia (PWA) and 30 control participants watched videos of an actor communicating a message in three different conditions: verbal only, gesture only, and verbal and gesture message combined. The message related to an action in which the name of the action (e.g., 'eat') was provided verbally and the manner of the action (e.g., hands in a position as though eating a burger) was provided gesturally. Participants then selected a picture that 'best matched' the message conveyed from a choice of four pictures which represented a gesture match only (G match), a verbal match only (V match), an integrated verbal-gesture match (Target) and an unrelated foil (UR). To determine the gain that participants obtained from integrating gesture and speech, a measure of multimodal gain (MMG) was calculated. OUTCOMES & RESULTS: The PWA were less able to integrate gesture and speech than the control participants and had significantly lower MMG scores. When the PWA had difficulty integrating, they more frequently selected the verbal match. CONCLUSIONS & IMPLICATIONS: The findings suggest that people with aphasia can have difficulty integrating speech and gesture in order to obtain meaning. Therefore, when encouraging communication partners to use gesture alongside language when communicating with people with aphasia, education regarding the types of gestures that would facilitate understanding is recommended.

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.

Exploration of older and younger British adults' performance on The Awareness of Social Inference Test (TASIT).

BACKGROUND: Social perception is an important skill. One assessment that is commonly used to assess social perception abilities is The Awareness of Social Inference Test (TASIT). The only normative data available for this test are for Australian younger adults. Despite no normative data being available for British adults, the test is widely used in the UK with older and younger adults. There is a growing body of research that suggests that older adults have difficulty with skills associated with social perception. There is therefore a need to determine whether British adults, and more specifically British older adults, perform similarly to the Australian normative TASIT scores available in the manual. AIMS: To explore the differences between older and younger British adults' performance on TASIT, and to determine whether younger and older British adults perform similarly to the data from Australian adults in TASIT manual. METHODS & PROCEDURES: TASIT was administered to a total of 42 native British English speaking participants. The participants were split into two age groups 18-45 and 60-90 years. Comparisons were made between the two groups and the Australian data in TASIT manual. OUTCOMES & RESULTS: The younger British and Australian adults obtained similar scores on all parts of TASIT. The older British adults though, obtained significantly lower scores than the Australian younger adults on all parts of TASIT and when education was controlled for they obtained significantly lower scores than the British younger adults. CONCLUSIONS & IMPLICATIONS: The findings are discussed in the light of previous research that has found that older adults are worse than younger adults at social inferences. The findings of the current study suggest that caution should be used when using TASIT with older British adults to assess social perception abilities.

The language-gesture connection: Evidence from aphasia.

A significant body of evidence from cross-linguistic and developmental studies converges to suggest that co-speech iconic gesture mirrors language. This paper aims to identify whether gesture reflects impaired spoken language in a similar way. Twenty-nine people with aphasia (PWA) and 29 neurologically healthy control participants (NHPs) produced a narrative discourse, retelling the story of a cartoon video. Gesture and language were analysed in terms of semantic content and structure for two key motion events. The aphasic data showed an influence on gesture from lexical choices but no corresponding clausal influence. Both the groups produced gesture that matched the semantics of the spoken language and gesture that did not, although there was one particular gesture-language mismatch (semantically "light" verbs paired with semantically richer gesture) that typified the PWA narratives. These results indicate that gesture is both closely related to spoken language impairment and compensatory.

Language and iconic gesture use in procedural discourse by speakers with aphasia.

Background: Conveying instructions is an everyday use of language, and gestures are likely to be a key feature of this. Although co-speech iconic gestures are tightly integrated with language, and people with aphasia (PWA) produce procedural discourses impaired at a linguistic level, no previous studies have investigated how PWA use co-speech iconic gestures in these contexts. Aims: This study investigated how PWA communicated meaning using gesture and language in procedural discourses, compared with neurologically healthy people (NHP). We aimed to identify the relative relationship of gesture and speech, in the context of impaired language, both overall and in individual events. Methods & Procedures: Twenty-nine PWA and 29 NHP produced two procedural discourses. The structure and semantic content of language of the whole discourses were analysed through predicate argument structure and spatial motor terms, and gestures were analysed for frequency and semantic form. Gesture and language were analysed in two key events, to determine the relative information presented in each modality. Outcomes & Results: PWA and NHP used similar frequencies and forms of gestures, although PWA used syntactically simpler language and fewer spatial words. This meant, overall, relatively more information was present in PWA gesture. This finding was also reflected in the key events, where PWA used gestures conveying rich semantic information alongside semantically impoverished language more often than NHP. Conclusions: PWA gestures, containing semantic information omitted from the concurrent speech, may help listeners with meaning when language is impaired. This finding indicates gesture should be included in clinical assessments of meaning-making.