High-Intensity Aphasia Intervention Is Minimally Fatiguing in Chronic Aphasia: An Analysis of Participant Self-Ratings From a Large Randomized Controlled Trial.

BACKGROUND: High-intensity therapy is recommended in current treatment guidelines for chronic poststroke aphasia. Yet, little is known about fatigue levels induced by treatment, which could interfere with rehabilitation outcomes. We analyzed fatigue experienced by people with chronic aphasia (>6 months) during high-dose interventions at 2 intensities. METHODS: A retrospective observational analysis was conducted on self-rated fatigue levels of people with chronic aphasia (N=173) collected during a previously published large randomized controlled trial of 2 treatments: constraint-induced aphasia therapy plus and multi-modality aphasia therapy. Interventions were administered at a higher intensity (30 hours over 2 weeks) or lower intensity (30 hours over 5 weeks). Participants rated their fatigue on an 11-point scale before and after each day of therapy. Data were analyzed using Bayesian ordinal multilevel models. Specifically, we considered changes in self-rated participant fatigue across a therapy day and over the intervention period. RESULTS: Data from 144 participants was analyzed. Participants were English speakers from Australia or New Zealand (mean age, 62 [range, 18-88] years) with 102 men and 42 women. Most had mild (n=115) or moderate (n=52) poststroke aphasia. Median ratings of the level of fatigue by people with aphasia were low (1 on a 0-10-point scale) at the beginning of the day. Ratings increased slightly (+1.0) each day after intervention, with marginally lower increases in the lower intensity schedule. There was no evidence of accumulating fatigue over the 2- or 5-week interventions. CONCLUSIONS: Findings suggest that intensive intervention was not associated with large increases in fatigue for people with chronic aphasia enrolled in the COMPARE trial (Constraint-Induced or Multimodality Personalised Aphasia Rehabilitation). Fatigue did not change across the course of the intervention. This study provides evidence that intensive treatment was minimally fatiguing for stroke survivors with chronic aphasia, suggesting that fatigue is not a barrier to high-intensity treatment.

Aphasia disrupts usual care: "I'm not mad, I'm not deaf" - the experiences of individuals with aphasia and family members in hospital.

PURPOSE: Communication difficulties are highly prevalent in the stroke population, with implications for patient experience, safety and outcomes. This study explores the experiences of people with aphasia and family members regarding healthcare communication in acute and subacute stroke settings. METHODS AND MATERIALS: A phenomenological approach was used to understand participants' experiences. Participants took part in a focus group and data were analysed using an inductive thematic approach. RESULTS: For individuals with aphasia (n = 4) and family members (n = 2), five themes were generated: "aphasia makes it hard to communicate," "hospital staff focus on the patient's medical status only," "people with aphasia do not get the help they need to improve," "staff lack the skills to communicate with people with aphasia," and "staff are crucial to improving healthcare communication." CONCLUSIONS: The stroke team has expertise in the medical management of stroke but struggle to communicate with patients with aphasia. Patients' experience of healthcare communication is often one-way and limited to following instructions, with missed opportunities to discuss core topics such as prognosis, rehabilitation, and person-specific needs. Patients and families assert that all members of the stroke healthcare team should be able to adapt communication to accommodate patients.

Person-centred care is not a reality for many patients with aphasia.Many healthcare conversations, including informal assessments and discussing prognosis, are not accessible for people with aphasia.Consequently, for people with aphasia, healthcare in hospital is characterised by confusion and exclusion.Staff are crucial to improving healthcare communication; when appropriate strategies were used, these were not only effective but very meaningful to patients.

High-Intensity Aphasia Therapy Is Cost-Effective in People With Poststroke Aphasia: Evidence From the COMPARE Trial.

BACKGROUND: Evidence from systematic reviews confirms that speech and language interventions for people with aphasia during the chronic phase after stroke (>6 months) improve word retrieval, functional communication, and communication-related quality of life. However, there is limited evidence of their cost-effectiveness. We aimed to estimate the cost per quality-adjusted life year gained from 2 speech and language therapies compared with usual care in people with aphasia during the chronic phase (median, 2.9 years) after stroke. METHODS: A 3-arm, randomized controlled trial compared constraint-induced aphasia therapy plus (CIAT-Plus) and multimodality aphasia therapy (M-MAT) with usual care in 216 people with chronic aphasia. Participants were administered a standardized questionnaire before intervention and at 12 weeks after the 2-week intervention/control period to ascertain health service utilization, employment changes, and informal caregiver burden. Unit prices from Australian sources were used to estimate costs in 2020. Quality-adjusted life years were estimated using responses to the EuroQol-5 Dimension-3 Level questionnaire. To test uncertainty around the differences in costs and outcomes between groups, bootstrapping was used with the cohorts resampled 1000 times. RESULTS: Overall 201/216 participants were included (mean age, 63 years, 29% moderate or severe aphasia, 61 usual care, 70 CIAT-Plus, 70 M-MAT). There were no statistically significant differences in mean total costs ($13 797 usual care, $17 478 CIAT-Plus, $11 113 M-MAT) and quality-adjusted life years (0.19 usual care, 0.20 CIAT-Plus, 0.20 M-MAT) between groups. In bootstrapped analysis of CIAT-Plus, 21.5% of iterations were likely to result in better outcomes and be cost saving (dominant) compared with usual care. In contrast, 72.4% of iterations were more favorable for M-MAT than usual care. CONCLUSIONS: We observed that both treatments, but especially M-MAT, may result in better outcomes at an acceptable additional cost, or potentially with cost savings. These findings are relevant in advocating for the use of these therapies for chronic aphasia after stroke.

Co-constructed communication therapy for individuals with acquired brain injury: A systematic review.

BACKGROUND: Meaningful, varied, joyful conversation is an important therapy target for adults with language or cognitive-communication disorders following acquired brain injury (ABI). However, the complexity of daily communication is often reduced to component parts within intervention programmes, with mixed evidence of generalization to everyday conversation. Interventions targeting co-construction of communication within a dyad offer a structured way in which to retain and treat elements of everyday conversation for individuals and their communication partner (CP). Such interventions exist but they are variably labelled, target different ABI populations and have not been synthesized. AIMS: To identify the nature, scope and effects of intervention studies targeting co-constructed communication in adults with ABI. METHOD: This systematic review was completed using PRISMA Guidelines. Six databases (MEDLINE, Embase, CINAHL, Scopus, LLBA, PsychInfo) were searched and 1210 studies were screened. Data were extracted and studies were rated for methodological quality and completeness of reporting. Outcome measures and effects of treatment were collated through descriptive synthesis. MAIN CONTRIBUTION: This review highlights an emerging evidence base in relation to an intervention approach that targets everyday communication. Co-constructed communication interventions have been reported by 13 studies, from a total of 206 participants with post-stroke aphasia, traumatic brain injury and progressive language impairments. These interventions take a range of formats, including referential communication tasks, retell/recount therapies and communication training programmes. Methodological quality evaluation indicated mostly low-level study designs. Heterogeneity was identified in primary outcome measures, with 28 unique primary outcome measures reported across studies. Most studies demonstrated change in task-specific or broad communication outcome measures. CONCLUSIONS: Co-constructed communication interventions may offer clinicians a systematic, protocolized, replicable way to target everyday communication for adults with ABI. More high-quality, experimental designs with complete reporting and psychometrically sound outcome measures are needed to strengthen the evidence base. WHAT THIS PAPER ADDS: What is already known on this subject Everyday conversation is an important therapy target for adults with ABI, but there is mixed evidence of therapy gains generalizing to everyday life. Many interventions reduce conversation to component parts such as naming or sentence construction. A different approach is needed to capture the social, dyadic, interactive and multifaceted nature of conversation. We propose the term 'co-constructed communication interventions' as a therapy genre targeting semi-structured dialogue. These interventions retain elements of everyday conversation (such as multimodal communication and situating tasks within dyads), combined with experimental elements (where stimuli prompt interactions and responses can be scored against normative data). What this paper adds to existing knowledge This review proposes and describes a distinct genre of discourse intervention within the current evidence base with a novel operational definition of 'co-constructed communication'. What are the potential or actual clinical implications of this work? Co-constructed communication interventions directly target elements of everyday communication by situating the therapy goals within a dyadic, interactive, multimodal task. A range of intervention tasks have been identified, including collaborative storytelling and problem-solving. This review will be of interest to clinicians working with adults with ABI; co-constructed communication interventions may offer a useful, replicable way to target aspects of everyday communication. This synthesis of the current evidence base encourages clinicians' informed, evidence-based decisions around these interventions.

Acceptability, feasibility and preliminary efficacy of low-moderate intensity Constraint Induced Aphasia Therapy and Multi-Modality Aphasia Therapy in chronic aphasia after stroke.

BACKGROUND: High-intensity Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) and Multi-Modality Aphasia Therapy (M-MAT) are effective interventions for chronic post-stroke aphasia but challenging to provide in clinical practice. Providing these interventions may be more feasible at lower intensities, but comparative evidence is lacking. We therefore explored feasibility, acceptability, and preliminary efficacy of the treatments at a lower intensity. METHODS: A multisite, single-blinded, randomized Phase II trial was conducted within the Phase III COMPARE trial. Groups of participants with chronic aphasia from the usual care arm of the COMPARE trial were randomized to M-MAT or CIAT-Plus, delivered at the same dose as the COMPARE trial but at lower intensity (6 hours/week × 5 weeks rather than 15 hours/week × 2 weeks). Blinded assessors measured aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient), word retrieval, connected speech, multimodal communication, functional communication, and quality of life immediately post interventions and after 12 weeks. Feasibility and acceptability were explored. RESULTS: Of 70 eligible participants, 77% consented to the trial; 78% of randomized participants completed intervention and 98% of assessment visits were conducted. Fatigue and distress ratings were low with no related withdrawals. Adverse events related to the trial (n = 4) were mild in severity. Statistically significant treatment effects were demonstrated on word retrieval and functional communication and both interventions were equally effective. CONCLUSIONS: Low-moderateintensity CIAT-Plus and M-MAT were feasible and acceptable. Both interventions show preliminary efficacy at a low-moderate intensity. These results support a powered trial investigating these interventions at a low-moderate intensity.

Towards efficient, ecological assessment of interaction: A scoping review of co-constructed communication.

BACKGROUND: The complexity of communication presents challenges for clinical assessment, outcome measurement and intervention for people with acquired brain injury. For the purposes of assessment or treatment, this complexity is usually managed by isolating specific linguistic functions or speech acts from the interactional context. Separating linguistic functions from their interactional context can lead to discourse being viewed as a static entity comprised of discrete features, rather than as a dynamic process of co-constructing meaning. The ecological validity of discourse assessments which rely on the deconstruction of linguistic functions is unclear. Previous studies have reported assessment tasks that preserve some of the dialogic features of communication, but as yet, these tasks have not been identified as a distinct genre of assessment. We suggest the term 'co-constructed communication' to describe tasks which are specifically designed to capture the dynamic, jointly produced nature of communication within a replicable assessment task. AIMS: To identify and summarize how co-constructed communication has been assessed with individuals with non-progressive acquired communication disability regarding task design, measures and psychometric robustness. METHODS: A scoping review methodology was used to identity relevant studies. Systematic database searches were conducted on studies published before July 2021. Studies in the yield were assessed against eligibility criteria, with 37 studies identified as eligible for inclusion. MAIN CONTRIBUTION: This is the first time that co-constructed communication has been defined as a genre of discourse assessment for stroke and traumatic brain injury populations. Co-constructed communication has been assessed for 144 individuals with aphasia and 111 with cognitive-communication disability. Five categories of co-constructed communication tasks were identified, ranging in complexity. Variability exists in how these assessment tasks are labelled and measured. Assessment measures require further psychometric profiling, specifically regarding test-retest reliability and validity. CONCLUSIONS: Co-constructed communication is a discourse genre which offers researchers and clinicians a replicable method to assess language and communication in an experimentally rigorous way, within an ecologically valid context, bridging the gap between experimental and ecological assessment approaches. WHAT THIS PAPER ADDS: What is already known on this subject Standardized assessments of language skills and monologue offer reliable, replicable ways to measure language. However, isolating language from an interactional context fundamentally changes the behaviour under study. This raises questions about the ecological validity of the measures we routinely use to determine diagnoses, guide treatment planning and measure the success of treatment. What this study adds to the existing knowledge This review highlights studies that conceptualize, and often quantify, interaction by combining experimental rigour and aspects of everyday dialogue. This is the first time this genre of discourse assessment has been identified. We propose the term 'co-constructed communication' to describe this genre and provide an operational definition for the term. What are the practical and clinical implications of this study? Co-constructed communication assessment tasks require refinement, particularly regarding aspects of psychometric robustness. In the future, these tasks offer pragmatic, meaningful ways to capture the effect and impact of aphasia and cognitive-communication disability within interaction.

Preventing depression in aphasia: A cluster randomized control trial of the Aphasia Action Success Knowledge (ASK) program.

BACKGROUND: Stroke patients with aphasia and their caregivers have higher incidence of depression than those without aphasia. AIMS: The objective of the study is to determine whether a tailored intervention program (Action Success Knowledge; ASK) led to better mood and quality of life (QoL) outcomes than an attention control with a 12-month end point at cluster and individual participant level. METHODS: A multi-site, pragmatic, two-level single-blind cluster randomized controlled trial compared ASK to an attention control (secondary stroke prevention program). Ten metropolitan and 10 non-metropolitan health regions were randomized. People with aphasia and their family members were recruited within 6 months post-stroke who scored ⩽12 on the Stroke Aphasic Depression Questionnaire Hospital Version-10 at screening. Each arm received manualized intervention over 6-8 weeks followed by monthly telephone calls. Blinded assessments of QoL and depression were taken at 12 months post-onset. RESULTS: Twenty clusters (health regions) were randomized. Trained speech pathologists screened 1744 people with aphasia and 373 participants consented to intervention (n = 231 people with aphasia and 142 family members). The attrition rate after consent was 26% with 86 and 85 participants with aphasia in the ASK arm and attention control arm, respectively, receiving intervention. Of those 171 who did receive treatment, only 41 met the prescribed minimum dose. Multilevel mixed effects modeling under the intention-to-treat protocol showed a significant difference on the Stroke and Aphasia Depression Questionnaire-21 (SADQ-21, N = 122, 17 clusters) in favor of the attention control (ß = -2.74, 95% confidence interval (CI) = -4.76 to -0.73, p = 0.008). Individual data analysis using a minimal detectable change score for the SADQ-21 showed the difference was not meaningful. CONCLUSION: ASK showed no benefit over attention control in improving mood and preventing depression in people with aphasia or their family members.

Acute post-stroke aphasia management: An implementation science study protocol using a behavioural approach to support practice change.

BACKGROUND: Evidence should guide decisions in aphasia practice across the continuum of stroke care; however, evidence-practice gaps persist. This is particularly pertinent in the acute setting where 30% of people with stroke will have aphasia, and speech pathologists experience many challenges implementing evidence-based practice. This has important consequences for people with aphasia and their close others, as well as speech pathologists working in acute settings. AIMS: This study protocol details how we will target practice change using a behavioural approach, with the aim of promoting the uptake of synthesized evidence in aphasia management post-stroke in the acute hospital setting. METHODS & PROCEDURES: We will conduct a mixed-methods before-and-after study following the Knowledge-to-Action (KTA) framework. Researchers, speech pathologists and people with lived experience of aphasia will collaborate to identify and prioritize practice gaps, and develop and implement changes to clinical practice based on the Theoretical Domains Framework and Behaviour Change Wheel. DISCUSSION: This study may provide a template for acute stroke services in how to use an implementation science approach to promote the application of synthesized evidence into routine clinical practice to ensure people with aphasia receive high-quality services. Collaboration among researchers, healthcare providers, people with aphasia and their close others ensures that the identification and targeting of practice gaps are driven by theory, lived experience and the local context. WHAT THIS PAPER ADDS: What is already known on this subject Synthesized evidence, such as clinical guidelines and consensus statements, provides the highest level of evidence to inform clinical practice, yet discrepancies between delivered care and evidence remain. This discrepancy is of note in the acute setting where clinicians report many challenges implementing the best available evidence, combined with a high proportion of people with stroke who will have aphasia (30%). There are many reasons why evidence is not put into practice, and efforts to change clinical practice need to consider these barriers when developing interventions. What this paper adds to existing knowledge This study protocol details an implementation science approach to affect clinical practice change, informed by a collaboration of key stakeholders (researchers, speech pathologists, and people with aphasia and their close others). Protocol papers that focus on bridging the gap between evidence and practice are uncommon in communication disorders; moreover, explicit prioritization of practice gaps is a critical but often overlooked aspect of promoting evidence-based practice. What are the potential or actual clinical implications of this work? This protocol provides insights into how one study site identified and prioritized evidence-practice gaps using a participatory approach. We provide insights into how clinical practice change may occur by describing how we plan to identify priority evidence-practice gaps and develop an intervention to improve the use of aphasia evidence in routine practice. This protocol aims to share an implementation science approach to service improvement that may be replicated across other services.

Conversation as an Outcome of Aphasia Treatment: A Systematic Scoping Review.

PURPOSE: Conversation-focused speech-language pathology services are a top priority for people living with aphasia, but little is known about how researchers measure conversation as an outcome of treatment. This scoping review was undertaken to systematically review the evidence regarding the measurement of conversation in aphasia studies and to identify current practices and existing gaps. METHOD: A systematic literature search was conducted for studies published between January 1995 and September 2019 in multiple electronic databases. Covidence software was used to manage search results, study selection, and data charting processes. Data were extracted from each study and then collated and organized to elucidate the breadth of approaches, tools, or procedures oriented to measuring conversation as an outcome and identify gaps in the existing literature. RESULTS: The systematic search of the literature resulted in 1,244 studies. A total of 64 studies met inclusion criteria and were included in the review. The review summarizes the various tools and procedures used to measure conversation as an outcome of aphasia intervention, including variations in data collection and analysis procedures. The review also evaluates the quality of conversation measures in terms of psychometric properties and informal measures of validity. There was a total of 211 measures used across the 64 studies. CONCLUSIONS: While there was no clear measure that was objectively superior, several measures show promise and warrant future exploration. Some of the orientations, conceptualizations, and procedures we have presented can be seen as options that might be included in a future conversation-focused core outcome set. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21514062.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia.

BACKGROUND: While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity. METHODS: We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs. RESULTS: We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up. CONCLUSIONS: CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses. TRIAL REGISTRATION NUMBER: ACTRN 2615000618550.

Dose effects in behavioural treatment of post-stroke aphasia: a systematic review and meta-analysis.

PURPOSE: Aphasia is a debilitating chronic acquired language disorder that impacts heavily on a person's life. Behavioural treatments aim to remediate language processing skills or to enhance communication between the person with aphasia and others, and a number of different treatments are efficacious. However, it is unclear how much of a particular treatment a person needs in order to optimise recovery of language and communication skills following stroke. MATERIALS AND METHODS: Systematic search for and meta-analysis of experimental studies that directly compared different amounts of the same behavioural aphasia treatment, following PRISMA guidelines. RESULTS: Treatment dose research in aphasia is an emerging area. Just six studies comparing different doses of the same intervention met all criteria for inclusion. Evidence from these studies was synthesised and meta-analysed, where possible. Meta-analyses were inconclusive due to limited data; however, there are indications that suggest increased dose may confer greater improvement on language and communication measures, but with diminishing returns over time. Aphasia severity and chronicity may affect dose-response relationships. CONCLUSIONS: There is currently insufficient evidence to determine the effect of dose on treatment response. A dedicated and coordinated research agenda is required to systematically explore dose-response relationships in post-stroke aphasia interventions.A video abstract is available in the Supplementary Material.Implications for rehabilitationThe investigation of the effect of dose on treatment outcomes in post-stroke aphasia is an emerging research area with few studies reporting comparison of different amounts of the same intervention.In the acute phase of recovery following stroke, higher doses of treatment provided over short periods may not be preferable, tolerable, or superior to lower doses of the same treatment.In the chronic phase, providing additional blocks of treatment may confer additional benefit for some people with aphasia but with diminishing returns.People with chronic aphasia can achieve and maintain significant gains in picture naming after a relatively brief period of high-dose treatment.

Statistical analysis plan for the COMPARE trial: a 3-arm randomised controlled trial comparing the effectiveness of Constraint-induced Aphasia Therapy Plus and Multi-modality Aphasia Therapy to usual care in chronic post-stroke aphasia (COMPARE).

BACKGROUND: While high-quality meta-analyses have confirmed the effectiveness of aphasia therapy after stroke, there is limited evidence for the comparative effectiveness of different aphasia interventions. Two commonly used interventions, Constraint-induced Aphasia Therapy Plus (CIAT Plus) and Multi-modality Aphasia Therapy (M-MAT), are hypothesised to rely on diverse underlying neural mechanisms for recovery and may be differentially responsive to aphasia severity. COMPARE is a prospective randomised open-blinded end-point trial designed to determine whether, in people with chronic post-stroke aphasia living in the community, CIAT Plus and M-MAT provide greater therapeutic benefit compared to usual care, are differentially effective according to aphasia severity, and are cost-effective. This paper details the statistical analysis plan for the COMPARE trial developed prior to data analysis. METHODS: Participants (n = 216) are randomised to one of three arms, CIAT Plus, M-MAT or usual care, and undertake therapy with a study trained speech pathologist in groups of three participants stratified by aphasia severity. Therapy occurs for 3 h blocks per day for 10 days across 2 weeks. The primary clinical outcome is aphasia severity as measured by the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ) immediately post intervention. Secondary outcomes include WAB-R-AQ at 12-week follow-up, and functional communication, discourse efficiency, multimodal communication, and health-related quality of life immediately post intervention and at 12-week follow-up. RESULTS: Linear mixed models (LMMs) will be used to analyse differences between M-MAT and UC, and CIAT-Plus and UC on each outcome measure immediately and at 12 weeks post-intervention. The LMM for WAB-R-AQ will assess the differences in efficacy between M-MAT and CIAT-Plus. All analyses will control for baseline aphasia severity (fixed effect) and for the clustering effect of treatment groups (random effect). DISCUSSION: This trial will provide relative effectiveness data for two common interventions for people with chronic post-stroke aphasia, and highlight possible differential effects based on aphasia severity. Together with the health economic analysis data, the results will enable more informed personalised prescription for aphasia therapy after stroke. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN 12615000618550 . Registered on 15 June 2016.

Aphasia disrupts usual care: the stroke team's perceptions of delivering healthcare to patients with aphasia.

PURPOSE: Communication disability, including aphasia, is prevalent in the stroke population and impacts service delivery. This study explored the experiences of the multidisciplinary stroke team in delivering healthcare to patients with aphasia. MATERIALS AND METHODS: A phenomenological approach was used to understand the experiences of delivering healthcare services in the presence of aphasia. Healthcare professionals (n = 16) were recruited across acute and subacute stroke care, with a range of discipline backgrounds and experience. Participants took part in focus groups and data were analysed using an inductive thematic approach. RESULTS: Five themes were evident: 1) aphasia is time consuming, 2) health professionals do not know how to help, 3) health professionals limit conversations with patients with aphasia, 4) health professionals want to know how to help, and 5) health professionals feel good after successful communication. CONCLUSIONS: Aphasia disrupts usual care. Health professionals want to help but are working in a non-optimal environment where communication and patient-centred care are not adequately resourced. A video abstract is available in Supplementary Material.IMPLICATIONS FOR REHABILITATIONCurrent hospital systems and ward culture make it difficult to offer patient-centred care to patients with aphasia.Health professionals want to help patients with aphasia but are working in an environment where patient-provider communication is not adequately resourced.As a result, health professionals dread, limit or avoid talking with patients with aphasia.Health professionals need support which may include ongoing education and on-the-job training, and a change in ward culture including key performance indicators focusing on patient-provider communication.

Treatment dose in post-stroke aphasia: A systematic scoping review.

Little is known about how the amount of treatment a person with aphasia receives impacts aphasia recovery following stroke, yet this information is vital to ensure effective treatments are delivered efficiently. Furthermore, there is no standard dose terminology in the stroke rehabilitation or aphasia literature. This scoping review aims to systematically map the evidence regarding dose in treatments for post-stroke aphasia and to explore how treatment dose is conceptualized, measured and reported in the literature. A comprehensive search was undertaken in June 2019. One hundred and twelve intervention studies were reviewed. Treatment dose (amount of treatment) has been conceptualized as both a measure of time and a count of discrete therapeutic elements. Doses ranged from one to 100 hours, while some studies reported session doses of up to 420 therapeutic inputs per session. Studies employ a wide variety of treatment schedules (i.e., session dose, session frequency, and intervention duration) and the interaction of dose parameters may impact the dose-response relationship. High dose interventions delivered over short periods may improve treatment efficiency while maintaining efficacy. Person- and treatment-level factors that mediate tolerance of high dose interventions require further investigation. Systematic exploration of dose-response relationships in post-stroke aphasia treatment is required.

Constraint-induced or multi-modal personalized aphasia rehabilitation (COMPARE): A randomized controlled trial for stroke-related chronic aphasia.

RATIONALE: The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown. AIMS AND HYPOTHESES: In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia. SAMPLE SIZE ESTIMATES: A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05. METHODS AND DESIGN: Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care). STUDY OUTCOMES: WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks. DISCUSSION: This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

Fidelity protocol for the Action Success Knowledge (ASK) trial: a psychosocial intervention administered by speech and language therapists to prevent depression in people with post-stroke aphasia.

INTRODUCTION: Treatment fidelity is a complex, multifaceted evaluative process which refers to whether a studied intervention was delivered as intended. Monitoring and enhancing fidelity is one recommendation of the TiDIER (Template for Intervention Description and Replication) checklist, as fidelity can inform interpretation and conclusions drawn about treatment effects. Despite the methodological and translational benefits, fidelity strategies have been used inconsistently within health behaviour intervention studies; in particular, within aphasia intervention studies, reporting of fidelity remains relatively rare. This paper describes the development of a fidelity protocol for the Action Success Knowledge (ASK) study, a current cluster randomised trial investigating an early mood intervention for people with aphasia (a language disability caused by stroke). METHODS AND ANALYSIS: A novel fidelity protocol and tool was developed to monitor and enhance fidelity within the two arms (experimental treatment and attention control) of the ASK study. The ASK fidelity protocol was developed based on the National Institutes of Health Behaviour Change Consortium fidelity framework. ETHICS AND DISSEMINATION: The study protocol was approved by the Darling Downs Hospital and Health Service Human Research Ethics Committee in Queensland, Australia under the National Mutual Acceptance scheme of multicentre human research projects. Specific ethics approval was obtained for those participating sites who were not under the National Mutual Agreement at the time of application. The monitoring and ongoing conduct of the research project is in line with requirements under the National Mutual Acceptance. On completion of the trial, findings from the fidelity reviews will be disseminated via publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12614000979651.

How Much Information Do People With Aphasia Convey via Gesture?

PURPOSE: People with aphasia (PWA) face significant challenges in verbally expressing their communicative intentions. Different types of gestures are produced spontaneously by PWA, and a potentially compensatory function of these gestures has been discussed. The current study aimed to investigate how much information PWA communicate through 3 types of gesture and the communicative effectiveness of such gestures. METHOD: Listeners without language impairment rated the information content of short video clips taken from PWA in conversation. Listeners were asked to rate communication within a speech-only condition and a gesture + speech condition. RESULTS: The results revealed that the participants' interpretations of the communicative intentions expressed in the clips of PWA were significantly more accurate in the gesture + speech condition for all tested gesture types. CONCLUSION: It was concluded that all 3 gesture types under investigation contributed to the expression of semantic meaning communicated by PWA. Gestures are an important communicative means for PWA and should be regarded as such by their interlocutors. Gestures have been shown to enhance listeners' interpretation of PWA's overall communication.

The Consequences of the Consequences: The Impact of the Environment on People With Aphasia Over Time.

Understanding the impact of the environment on the participation of people with aphasia depends on one's perspective. A long-term perspective provides a unique insight into the myriad of ways in which the environment can influence the participation of people living with aphasia over decades. In this article, the authors present the real-life story of "Hank," who has lived with aphasia for more than 15 years. The authors consider how 2 different conceptual frameworks-the International Classification of Functioning, Disability and Health and the Social Determinants of Health-account for Hank's experience. The International Classification of Functioning, Disability and Health is useful to conceptualize the range of factors that influence living with aphasia at a particular point in time. In contrast, the Social Determinants of Health is useful to conceptualize the cumulative impact of living with aphasia on long-term health and well-being. Viewing aphasia as a social condition that impacts social determinants of health has potentially wide ranging implications for service design and delivery and the role of speech-language pathologists.

Outcomes of treatment targeting syntax production in people with Broca's-type aphasia: evidence from psycholinguistic assessment tasks and everyday conversation.

BACKGROUND: Capturing evidence of the effects of therapy within everyday communication is the holy grail of aphasia treatment design and evaluation. Whilst impaired sentence production is a predominant symptom of Broca's-type aphasia, the effects of sentence production therapy on everyday conversation have not been investigated. Given the context-sensitive nature of spoken production by people with aphasia, it is difficult to extrapolate implications for everyday conversation based on results from task-based assessment (such as picture description, story retell or interview). Thus, there are strong theoretical and clinical motivations to investigate generalization from sentence production treatment to everyday conversation. AIMS: To evaluate a theoretically driven treatment focused on the language production skills of participants with post-stroke Broca's aphasia and to track outcomes from psycholinguistic assessment tasks to everyday conversation. METHODS & PROCEDURES: A case series design was utilized with pragmatic selection of participants with chronic aphasia undergoing the same assessment and treatment procedures. Nine participants with Broca's aphasia and their main conversation partners took part in the study. Treatment was implemented once weekly over 8 weeks and targeted production of basic syntax-two, three and four constituent constructions-through principles of mapping and reduced syntax treatment. Use of different possible exemplars for nouns, particularly pronouns, was trained together with use of both light and heavy verbs. Participants had the opportunity to 'top-up' therapy practise by completely a homework task that mirrored the therapy task. OUTCOMES & RESULTS: Syntactic well-formedness was assessed in samples of constrained sentence production, narrative retell and naturally occurring conversations at baseline, 1 week post-treatment, and 1 month post-treatment. Treatment showed strong direct effects in trained and untrained sentence construction tasks, with some generalization to narrative retell tasks. There was little evidence of change in everyday conversation. CONCLUSIONS & IMPLICATIONS: Improvement in language production in constrained assessment tasks may not impact on everyday conversations. Implications for further research are discussed, e.g. the need for bridging interventions between constrained and unconstrained contexts of language production. Clinical implications include the potential to streamline therapy planning and delivery by making use of rich, hybrid therapies to treat individuals with similar symptom profiles but with a range of underlying deficits.

The effects of verb retrieval therapy for people with non-fluent aphasia: evidence from assessment tasks and conversation.

Despite often impressive improvements on linguistic assessments, there is a lack of evidence of significant generalisation from impairment-focused aphasia therapy to everyday communication. The aim of the current study was to investigate the effect of a verb retrieval therapy across a range of levels of language production. Nine participants with chronic non-fluent stroke aphasia were recruited into this case series. Baseline assessment included naming a range of verbs (i.e., action verbs, semantically light verbs and personally relevant verbs) and sentence production. Multiple samples of conversation were collected from each participant and his/her partner. Consecutively failed verbs were divided across treatment and control sets; these sets were matched for salient psycholinguistic variables such as frequency, imageability and argument structure. A multi-component verb retrieval therapy was delivered, consisting of semantic feature analysis, gesture production and phonemic cueing. Following therapy, participants demonstrated significant and sustained gains in naming treated verbs; more modest effects were seen in untreated verbs. Mixed patterns of generalisation were evident in assessment of sentence production. In conversation, while group analysis suggested a lack of change, individual analyses indicated increased verb retrieval for three participants and qualitative changes related to the syntactic contexts of verbs retrieved.